Tuesday, January 12, 2010

Health IT Strategic Framework

The HIT Policy Committee Strategic Planning Workgroup met on Tuesday, January 12, 2010. Document and transcript are below.

Workgroup Member List:

  • Paul Tang, Palo Alto Medical Center, Chair
  • Jodi Daniel, ONC, Co-Chair
  • Roger Baker, Department of Veterans Affairs
  • Christine Bechtel, National Partnership for Women & Families
  • Patricia F. Brennan, University of Wisconsin
  • Janet Corrigan, National Quality Forum
  • Art Davidson, Denver Public Health
  • Don Detmer, American Medical Informatics Association (retired)
  • Carol Diamond, Markle Foundation
  • Paul Egerman, Consultant
  • Steve Findlay, Consumers Union
  • Mark Frisse, Vanderbilt University
  • Charles Kennedy, WellPoint, Inc.
  • John Lumpkin, Robert Wood Johnson Foundation
  • Dave McCallie, Cerner Corporation





Transcript of

Strategic Plan Workgroup

January 12, 2010

Paul Tang, Palo Alto Medical Foundation, Internist, VP & CMIO

Thank you very much, Judy, and welcome everyone to our second Strategic Planning Workgroup Call. A lot of work has been going on to flush out some of the things that we talked about last time, and we will be checking in to bring it all together.

Just to remind folks, this is a several-months process; we don’t have our final delivery until May. The processes we are going to be updating the full committee tomorrow at its full committee meeting, and that means we already talked about the four themes; we’re going to present some of the work that we’re going to discuss today, meaning the vision principals and objectives under each theme for further comments. It’s not a long presentation at the committee but we’ll get additional comments and see if we’re on the right track.

We’ll then be talking, flushing out more of the – we’ve gotten down to the objectives and we haven’t talked too much about strategies to this point so we’ll flush that out before we get presenting again at the February meeting. And it won’t be until March until when we deliver our first draft of the full document that we have a really good handle on, I think, already. And when we get the approval and further comments from the full committee, we’ll be putting that out to the public for a listening session in April before we finally pen our final draft for approval before submitting it to ONC.

So we have a lot of time for feedback is the point. And today, like before, we’ll be working on the principals and objectives for each theme. I’m not working on the word by word words missing, but make sure we have all the concepts correct.

So Jodi, do you want to add anything?

Jodi Daniel – ONC – Director Office of Policy & Research

No, I think you did a great job; I think we’ve got a lot to do so we should probably just jump right in.

Paul Tang, Palo Alto Medical Foundation, Internist, VP & CMIO

Okay.

Deven McGraw, Center for Democracy & Technology, Director

This is Deven; can I just ask a question about how much we hope to finalize here today because I have to admit, I didn’t have a chance to read these materials. … … because we didn’t get them until late yesterday.

Paul Tang, Palo Alto Medical Foundation, Internist, VP & CMIO

Right. It’s still pretty high level, Deven.

Deven McGraw, Center for Democracy & Technology, Director

Okay.

Paul Tang, Palo Alto Medical Foundation, Internist, VP & CMIO

As I said, we’re not even at the initial draft so we’re basically – most of the stuff you’ll be able to read even during the call and we’re concentrating on the theme. I think we’ve pretty much nailed; it’s really the principals and the objectives.

Deven McGraw, Center for Democracy & Technology, Director

Okay, great, thanks; I appreciate that.

Jodi Daniel – ONC – Director Office of Policy & Research

This is Jodi; I’ll just jump in here. I think what we’re looking for tomorrow for the policy committee is really just some feedback from them. So I don’t think anything that we talk about here today is set in stone; I think we’re going to be looking for feedback from the full committee and then trying to bring that back and processing it as well. So, as Paul had said, this is not the last bite of the apple; there’s going to be a few more bites to the apple here. And we’re just hoping to get some discussion and get us to a better place when we present tomorrow to the policy committee we can have a good discussion with them and get their input on where things stand at this point.

Deven McGraw, Center for Democracy & Technology, Director

Thank you; thank you very much.

Carol Diamond – Markle Foundation – Managing Director Healthcare Program

Jodi, this is Carol. I have a question and if this was answered, sorry; I joined a few minutes late. So sorry if you have to repeat it. But some of us couldn’t get comments to you on Friday, but we got them in yesterday. Is this draft that we got last night going to reflect those comments? Or is this draft going to the committee? I’m just confused about where we are in the process.

Jodi Daniel – ONC – Director Office of Policy & Research

We did not have time to process the comments that we received late at this point; in other words, viewed yesterday. So they are not reflected in the draft that was sent forward, but if there are issues that people raise that they want to bring up in the discussion, that would be appropriate.

Carol Diamond – Markle Foundation – Managing Director Healthcare Program

So, well, I guess I’m asking: Will they be incorporated at some point or am I supposed to raise them all today?

Seth Pazinski, ONC, Special Assistant

I’m sorry, this is Seth. We will take those comments and incorporate those for a subsequent revision.

Carol Diamond – Markle Foundation – Managing Director Healthcare Program

Right, thank you.

Christine Bechtel, National Partnership for Women & Families, VP

And did this reflect the comments you did receive earlier. This is Christine and I was one of the late commenter’s as well, but I’m not sure if this reflects Art’s comments and Dawn’s comments or not.

Seth Pazinski, ONC, Special Assistant

Yes, the comments that came in as of Friday were incorporated into this draft; at least the ones that had – anything that sort of clarified something that wasn’t clear before or was discussed in the workgroup is incorporated into this draft. If it wasn’t, we just kind of flagged it to bring it up today on the call so that we could discuss it amongst the full workgroup.

Jodi Daniel – ONC – Director Office of Policy & Research

So there were some comments we received that just were kind of edit to what we did or that made things clearer or cleaner or that reflects the conversation we had. And then there were some new ideas or questions or issues that were raised as well in comments to us. And so some of those we have identified in our … Agenda as Discussion Item so that we hope to talk through them and others where we could just incorporate them and we thought that there was sufficient consensus on the concept, we incorporated them in the document. So some of them are captured in the discussion points for today and some of them are captured in the actual text of the document. That make sense? We tried to capture whatever we got in one place or another either as an edit or as a discussion point.

W

That makes sense.

Paul Tang, Palo Alto Medical Foundation, Internist, VP & CMIO

Okay. Why don’t we start moving through the document then and then we’ll sort of – we’ve … it up into about 30 minute chunks. Let’s see. I think the Background is pretty clear. Section Two, also, you have the redline version and the only things that have been done is sort of put in the official title – The Strategic Plan, i.e, The Federal Health IT Strategic Plan – that’s caught on the statute. So I think there are minor edits there. Before we get into Section Three, anything in Sections One and Two?

Okay, so we started our work last time really on the vision and guiding principals and some of the major things we did was sort of to pull in the IOM six aims and talk a bit about the use of the NPP Health Priorities, which is in sort of the second paragraph, and talking about how it fits into what was called the Learning Health System.

And then we had another subsection about guiding principals and someone’s comment was to … they’re sort of process principals, should they, in fact, be moved up to the process section, which is more Section Two. Any comments on that proposal?

W

Yes, Paul … and that was one of the comments that I made as well because I feel like to have guiding principals on an overall strategic plan that are largely process focused and only three of them wasn’t robust enough, and I think you could move two of them into another section and the third is sort of redundant. So I agree with actually taking B out entirely.

Paul Tang, Palo Alto Medical Foundation, Internist, VP & CMIO

Okay. Anyone have a problem with that? Okay, I think it just makes the document clearer. Another thing that was mentioned last time was the whole notion of values. Don had submitted a set of what he called “values” that we re-circulate to the group after or during the call. And as we tried to work that in – so, for example, one of the values was altruism; it wasn’t necessarily clear whether that’s something that we apply to this government office. It wasn’t clear whether this is something that belongs – it’s so general that it belongs in this particular document. So open to comments about that.

W

Paul, this is … . Can you point – is this in Don’s draft or is this included in this?

Paul Tang, Palo Alto Medical Foundation, Internist, VP & CMIO

It was just in Don’s; so it’s not included here and I don’t actually have that in front of me; somebody might have it. It was a little hard to work the general of values into this document as being specifically relevant to this document.

W

But I have to tell you that I liked Don’s attention to the values, but I don’t think it belongs in the guiding principal. But I wondered if there was going to be some kind of a preamble or maybe under what is in my document called the “Strategic Framework” dated January 11, page three. There’s a scope statement on page three under Roman II, letter A – Strategic Planning Scope, and the values could go in that section.

Paul Tang, Palo Alto Medical Foundation, Internist, VP & CMIO

Okay, or maybe some of the values?

W

Or some of the values. I mean I think the idea of sort of displaying at where we’re starting from with them I think is actually kind of important because if – those could be open for debate and they may changed the tenor of the document.

Jim Walker, Geisinger Health Systems, Chief Health Information Officer

This is Jim. I’m in the process of writing guiding principals for a Beacon community, actually as it turns out. When you read these – I can see what Don is talking about. For a set of guiding principals they’re very process-oriented; they’re very much about – they’re tactical actually and it wouldn’t be a bad way to characterize them. It does seem to me that it would make some sense and maybe part of the thing is to make it clear that the vision – how the vision and the principals relate to each other. Or maybe the problem is calling this Guiding Principals rather than Working Guidelines or something like that.

W

Oh, I see what you’re saying.

Jim Walker, Geisinger Health Systems, Chief Health Information Officer

Guiding Principals kind of suggest we’re going to do everything possible to make sure that patients and caregivers and providers are all benefited by the changes that are made, or that kind of more aspirational principal. That really what a principal kind of suggests rather than this more process sort of – how we’re going to manage the process kind of things here.

Paul Tang, Palo Alto Medical Foundation, Internist, VP & CMIO

Alright. So could I suggest that maybe a couple volunteers work on how we might use – and I’m guessing it’s still only a subset so … I mentioned was one, justice and community good is another. How can we use some of these in the right place in the right way? Perhaps we could have a little offline work to help us out with that one.

Jim Walker, Geisinger Health Systems, Chief Health Information Officer

And I just would make a specific recommendation that we also, somebody give some thought to what a really clear name for these three things, and perhaps other things, to go with them. But I don’t think Guiding Principals is the natural English for what they are.

Paul Egerman, eScription, CEO

This is Paul Egerman. We’re talking about this concept of values but there are some sort of values in the legislation dealing with like healthcare disparities and … at hospitals and disadvantaged populations. … don’t appear anywhere in this document.

Jim Walker, Geisinger Health Systems, Chief Health Information Officer

And I think that probably goes here is probably the first – those sorts of things. Maybe just two or three of them. I think those more operational expressions I bet are probably better than something like altruism, which then we can spend a couple pages defining. But if we included the things that you just said, I think that’s what is missing.

Paul Egerman, eScription, CEO

It seems we should request back some of the language that’s in ORU.

Jim Walker, Geisinger Health Systems, Chief Health Information Officer

Right.

W

I think that makes a lot of sense.

Paul Tang, Palo Alto Medical Foundation, Internist, VP & CMIO

I agree; I think that makes a lot of sense and I think the drafters of ORU actually – there’s a lot of good attributes to that. That….

Carol Diamond – Markle Foundation – Managing Director Healthcare Program

This is Carol. Can I make a corollary point here because I think it’s great to amend the guiding principals in that direction. Paul, I absolutely agree the law speaks to some of those things including reducing disparities, etcetera. But I’m struggling with the vision, which is so general and so big-picture that it’s not really a vision. And I would love to see us make a similar amendment to that section, which is to really be clear. The law speaks to – and now the regulation speaks to – some very clear health goals because there are metrics and measures to demonstrate meaningful use. And it would be great if those health goals could be captured in the vision, including things like reducing … patient, improving medication management, improving care coordination. I mean if that’s not the vision, I’m not sure what drives the measures and the demonstration of meaningful use. I just think it’s great to say, “You know, we want to improve quality and safe effective patients in a timely efficient equitable care is a good thing.” But I really think the vision has to be more specific in the context of: What it is that you’re setting out to achieve.

Marc Probst, Intermountain Healthcare, CIO

Yes, and Paul, this is Marc Probst – very much in agreement with the last statement. This is an HIT Strategic Plan and in the vision it seems like HIT is an after thought in the way the vision is set, which is what we’re trying to achieve with technology.

Paul Tang, Palo Alto Medical Foundation, Internist, VP & CMIO

Let me just recap a little bit about what we said on the last call. And I think most organizations when we get to the point of what a vision, mission, strategic objectives have this sort of semantic issue of what belongs in which category. I think we actually molded this vision to say what it says now because it had certain key concepts – learning, patient centered, uses information, improves health, and cost of individuals and populations. And interestingly, Marc, last time we specifically – and I think it was with Carol’s counsel – wanted to put our vision for the health system ahead of the use of HIT and, in fact, this almost deliberately doesn’t have the term HIT in it. We use information however that’s done and clearly HIT has a big role. I thought we actually pretty much nailed this vision last time as truly a high level vision rather than what some might call more strategic themes.

M

Is this vision consistent then with whomever … the broader vision because it seems to me this plan – there’s a scope that ONC has; does ONC control the scope of what this vision says or is this something that’s way exceeds what we can accomplish with this particular plan.

Paul Tang, Palo Alto Medical Foundation, Internist, VP & CMIO

Well I think as Paul Egerman mentioned in the statute there was sort of a hierarchy of purpose for even high tech, and the purpose was to improve health outcomes for individuals in the populations. And there are a number of other things, values that Paul mentioned – reduced disparities, etcetera. A lot of that’s actually captured in the category for meaningful use, which mirror the National Quality Forum’s NPP priorities. So I think the fact that the recovery act and the high tech provision in the recovery act set aside this health system vision. That’s what we’re trying to mirror. But, yes, that’s not for ONC alone to do. ONC’s role in the context of high tech is to put in place an information infrastructure, so to speak, that would support that vision, though. And so that – we’re sort of mirroring that kind of strategy or that hierarchy of goals.

M

Okay, well I came in late to this game, so I won’t delay with the topic.

Jodi Daniel – ONC – Director Office of Policy & Research

This is Jodi and we were just having a conversation here in the ONC room. I think the other thing we talked about last time and I agree actually with the point that ONC’s vision and authority is about health IT, not about this – we don’t control this whole vision. Our efforts will help support this vision, but will not in and of itself, result in this vision. I think what we talked about last time was giving some context in the discussion in this vision section about health IT’s role and meeting that vision so that we have sort of the lofty goal and we’re not working on technology for technology’s sake, but toward a larger vision, but then explaining in the discussion and we probably need to add that in here – some context for how the high tech efforts, how the ONC efforts have the … health IT efforts can support this vision and making that link.

So I think that was sort of the compromise that we came up with last time, and I don’t know that we had taken the time to actually flush that out. So we probably just need to do that and then hoping that that might resolve the concern.

M

I’ll belabor it one more step and then I promise I’ll be quiet. But if you go back to the strategic planning scope, it is much more specific to our vision.

Paul Tang, Palo Alto Medical Foundation, Internist, VP & CMIO

Well as Jodi mentioned – so if you look at the three sort of paragraphs, it says what Jodi said, which again was trying to reflect what this workgroup talked about, which is: What’s the vision for the health system, which again is in the recovery act, and then how do we support it? So we have a vision, we have sort of a discussion of: Well how do you support that vision by picking contemporary health priorities. And then the final sentence is: Oh, and HIT is such a component to make that happen.

So we could perhaps do better job in the word, but that would try to capture what was described last time.

M

Paul, where do we … by our vision then? … …

Paul Tang, Palo Alto Medical Foundation, Internist, VP & CMIO

Well I think what we decided was that it’s not an HIT vision; it’s not an HIT vision. We have some strategic objectives for how HIT supports the health systems vision – the vision for the health system.

Christine Bechtel, National Partnership for Women & Families, VP

… … and I strongly agree with where this is at plus Carol’s amendments because in part as Dr. Blumenthol has always said from the beginning of the policy committees inception that this about health reform and so I think when you ask where … … the HIT to me, it comes through in the principals, and the strategic and the principals that are under the objectives. I like to have the combination of both and I think Jodi made a good … … language that connects … … …

W

Christine, we keep losing you; you’re cutting in and out.

Christine Bechtel, National Partnership for Women & Families, VP

Oh, thanks, sorry.

Paul Tang, Palo Alto Medical Foundation, Internist, VP & CMIO

Okay, so how are we doing with this section – section three? Alright let’s move on to section four.

M

… … I just wanted to just recap the two things I heard were, one, to add some additional context around as an IT in the vision, and also the second point was to bring in the health outcomes piece more so to bring the meaningful use health outcomes up into this section.

Jodi Daniel – ONC – Director Office of Policy & Research

Yes, from ORU, for High Tech.

M

Well … … – anything to do with meaningful – you said it’s really in the statute it talks about some of its values, like reducing disparities, etcetera. And those are parts of the themes that we’re going to bring in. And then we also are going to have a few of us work on the sort of valued proposition. It’s a mixture of what was in the recovery act and some of Don’s points, and Jim Walker, one of the people who were working on that.

Carol Diamond – Markle Foundation – Managing Director Healthcare Program

In terms of the context in the vision section for HIT, the last paragraph is completely devoted, stating the role of HIT. I would love to see that made much more clear in terms of what the vision is linking HIT to the broader vision that’s articulated above. And again, I go back to the notion that the law really does set out a set of improvements that need to be achieved and goals that need to be achieved and I would love to see those here.

Patti Brennan, UW-Madison, Moehlman Bascom Professor

So Carol, are you suggesting that the paragraph that’s just above B should articulate a little bit more about how HIT is going to accomplish those or what HIT….?

Carol Diamond – Markle Foundation – Managing Director Healthcare Program

Yes. What are ONC’s goals for using HIT to achieve that broader vision, and I would argue that as the law says – and now the regulation has a set of measures that says you have to report on blood pressure, you have to report on medication management, blah, blah, blah – that this is the opportunity to say: You know, we believe we can contribute to this broader vision by making measurable improvements or demonstrating measurable improvements or setting forth a goal of having improvements in reducing hospital re-admissions, improving medication management, blah, blah, blah – whatever the big health goals are that are really already stated in the context of all the quality measures and all the data collection that’s going to happen. I mean it seems to me that this is the time to really set an organizing set of goals across the different agencies and other bodies that helps establish priorities and targets down the road.

Patti Brennan, UW-Madison, Moehlman Bascom Professor

If I am to understand you correctly, this is the place where we might put a stake in the ground and say: HIT is needed not only to collect the data, but also to ensure or to support the delivery of public education or the on-the-spot decision support necessary to accomplish these goals. And we may not go down to that level that explicitly of decision support system tools or consumer education, but we would indicate here that HIT plays a significant role in both supporting practice as well as documenting practice, or some such thing as that.

Carol Diamond – Markle Foundation – Managing Director Healthcare Program

My personal view is that it’s less about saying how the HIT is used and more about saying what it needs to be used for and what the vision and objective.

Patti Brennan, UW-Madison, Moehlman Bascom Professor

Yes, I get that. So it’s less mechanistic and more targeted.

M

Can we have a little further discussion on that because I found myself agreeing with the approach Patty was taking in terms of how does HIT support of the goals for the health system? And I think some of the specific areas you mentioned, Carol, might fit in if it’s a means to an end rather than the end. And perhaps in this section we’re talking a bit more about the end. And it may be that we want to measure blood pressure but that’s not the goal that we have; it’s a means to furthering the improving the health of the community or of individuals kind of goal. Does that make sense?

Carol Diamond – Markle Foundation – Managing Director Healthcare Program

Right. I’m arguing that needs to be stated somewhere. That goal needs to be made explicit. Because without it, it’s just a set of measures and I think this can really be the organizing principal around setting priorities and health objectives more broadly both within government and outside.

Art Davidson, Public Health Informatics at Denver Public Health, Director

This is Art, Paul. In the top part of the document, in the background, there are the eight points that came from legislation. Is that what you and Paul Egerman were referring to earlier and that we need to recapitulate in this paragraph, or are there other things? I’m trying to get clear what exactly would the language we could use.

Jim Walker, Geisinger Health Systems, Chief Health Information Officer

This is Jim. Why don’t we have Paul repeat. Paul had two or three or four really excellent examples. One was disparities. You’re addressing disparities. I think those are sort of intermediate levels that take us from the high values, the high level values to something that is concrete enough that people can form a clear idea in their minds. I think this is just about communication; to make the links between the high level values and what will come to the blood pressure. What is it that links those things and using the language of the law would be a very powerful way to link those high values and the blood pressure in a meaningful sort of grid.

Paul Tang, Palo Alto Medical Foundation, Internist, VP & CMIO

So, Jim, I think it is in number seven and I’ll read it, and Paul will let me know if this is it. So it says:

Strategies to enhance the use of HIT in improving the quality of healthcare, reducing medical errors, reducing health disparities, improving public health, increasing prevention in coordination with community resources, and improving the continuity of care among healthcare settings.

I think that’s the linking concepts, as you said.

Janet

This is Janet, and I think what I’m struggling with here is that we have on page four of the document under vision a brief description of the National Priorities Partnership and the specific priorities that were established there which were used by the policy committee and the standards committee in identifying … measures. Maybe we could just expand further on that to get specific examples, and they align very nicely with the project’s …. In the area of safety, maybe we want to point to the specific goal of the National Priorities Partnership to reduce healthcare-acquired infections to zero and then point to the HAI meaningful use measures and how the EHRs are going to help with achieving that particular goal. There are clearly other ones for care coordination that relate so much to the connectivity, the readmissions and other factors. These are a way to tie us back into that as opposed to coming up with other examples … to keep within our overall framework. … to do a one page appendix that just lists the six major national priorities and then maybe even the specific meaningful use measures for 2011 and 2013 that are likely to line up with that, to be very, very explicit about this being grounded in those national priorities that hopefully is going to … secretary will ….

Paul Tang, Palo Alto Medical Foundation, Internist, VP & CMIO

… I would say it’s a little bit cleaner to do it in your appendix style, Janet. I’m still recalling the discussion we had at the first call where people commented on sort of the elegance of this division statement that we had. It gets to sort of the how many people do you name and then you worry about who you forget to name, and when it’s so pristine, whether either it’s a division statement or the list of priorities from the NPP, I think we can explain maybe more about the process, but once we start naming things in this particular section (and I think there are places to names things to get specific within this sort of vision section) we run the risk of who we didn’t name. That’s the only caveat—

W

I guess what we were trying to get to is Carol’s concern about the specific examples, and maybe even if she doesn’t, I guess I know how to get more concrete about what those overarching priorities and goals are, and Carol was asking for a set of specific examples in those areas I think.

Carol

Yes, and I’ll go at it one more time, and then we can move on. I think it’s great to have an appendix with the NPP goals, but those are not the HHS goals, and I think the … needs to be established. Their vision needs to be established about what the national health priorities are, and this is a place to say either this set of high-level goals are the things we’re setting out to achieve and the details of the measures or anything underlying that is not really what’s necessary. I’m just struggling with a vision that says we want safe, effective, patient-centered, timely, efficient, equitable care which isn’t really an organizing vision. In other words, it’s a very broad saying, and I think within that there’s an opportunity to say, especially after the third paragraph which is the lead in to HIT, that public policy relating to the law should achieve improvements in health and healthcare in line with these six aims, and an initial set of vision-type health goals could be listed here that really set the bar on what it is that the whole strategic plan is aiming for and it needs to achieve.

Jodi Daniel, Director Office of Policy & Research, ONC

This is Jodi. Let me see if I can try to summarize what I think I heard, and we could make a suggestion here. I think what I’m hearing is some need for greater clarity on, a little more in depth than this very broad vision in the discussion about the kinds of things we’re trying to accomplish, improve care coordination, improve medication management, etc., but not in so much detail that we’re going to measures and very specific things at this point. Obviously, we need to be working on those and developing those and having Health IT support those. In this vision section I think what I’m hearing is that we need to have a little bit more specificity to make this real in the description, but not so in the weeds that we’re kind of tying hands as to what the priorities will be three years down the road.

Carol

Yes, that’s exactly right. That’s exactly the point I’m trying to make, and I think the opportunity to link this to why HIT is … in achieving those goals is critical.

W

Why don’t we, Seth, is that something you want to try to take a crack at?

Seth Pazinski, Special Assistant, ONC

Sure.

Jodi Daniel, Director Office of Policy & Research, ONC

Why don’t we try to take a crack at adding to this, probably adding another paragraph after the Health IT paragraph and maybe actually beefing up that Health IT paragraph a little bit and circulating that around for folks to comment on. I feel like we’ve had a great discussion on this, and we probably have at least enough to get our juices flowing and to try to put some pen to paper.

Paul Tang, Palo Alto Medical Foundation, Internist, VP & CMIO

That sounds like a good approach, Jodi. Is that okay, Carol?

Carol

Yes, great.

Jim

This is Jim. Just one note, I’d consider not just adding, but reworking so that it maybe doesn’t end up longer, just clearer.

Paul Tang, Palo Alto Medical Foundation, Internist, VP & CMIO

I think that’s good, too. This particular section I think we’ll want to make sure that it’s timeless. We don’t want to be updating this. I think this is the kind of thing that should be timeless and not subject to annual updates. I think when we get to themes and specifically objectives, those can change as priorities change.

Speaking of themes, we would be right on time if we moved, and I think we have an approach for how to update the next round, and I think that we have plenty of time between now and when our final due date is. Getting into strategic themes, we did have some work going on with smaller groups that flesh some of these out, and this is up for group discussion then.

The first theme is the meaningful use of health information technology, and you see before you sort of the principles and at least the objectives, and we didn’t really get down to the strategies. You might give yourself a little time to go through the goal principles and objectives. The goal really is a restatement of the five categories for meaningful use, and the principles talk about how we focus again on the health outcomes that are aligned with the national priorities set by National Consensus Groups that we support all the individuals and decision-makers which includes the patients and consumers to give them the right information at the right time when they have a need to know, that we would like the public and private sector to work together to improve health outcomes and that they should be coordinated and harmonized. (that’s part of where we discussed even all of the various public agencies along with the private sector), and that ONC be wise in the way it uses resources and in particular, dedicate the most to the areas of greatest need. We can talk about smaller practices, smaller hospitals, rural, and community health centers. Those are sort of the principles. How do they sound to this group now?

Christine Bechtel, Vice President, National Partnership for Women & Families

Hi, Paul, this is Christine. Can you hear me okay?

Paul Tang, Palo Alto Medical Foundation, Internist, VP & CMIO

Yes.

Christine Bechtel, Vice President, National Partnership for Women & Families

I had a couple of suggestions that I don’t need to go through because Seth has them, but I have one thing that I want to strongly advocate for and then a couple of additions and that is under number two where we talk about having access to the right information at the right time. I think we just need to stop after the right time because based on a need-to-know I think what we were talking about was when a provider is authorized by a patient, but how it comes off because of the parenthetical reference to patient’s and consumers is fairly sort of paternalistic, like when a patient has a need-to-know, and I don’t want to put us in the position of being interpreted that way. I wanted to suggest two changes, and one is to cut the sentence off after the right time and then the other is earlier in the sentence when we say to improve individual and population health. I would add ‘and reduce disparities.’

Paul Tang, Palo Alto Medical Foundation, Internist, VP & CMIO

Wonderful. Two sounds like a no-brainer. May I suggest a modification to your first principle? Ironically, as you probably know, this was put in to protect the privacy of individuals and confidentiality, and so should we just do a better job at finding how to word this so that it comes across clearly as intending that rather than dropping the reference to adequate protection for privacy?

Jodi Daniel, Director Office of Policy & Research, ONC

This is Jodi. Can I suggest an alternative? We have a whole theme … security, so I was wondering if we were really addressing that issue in the other theme. Obviously, all these themes have to work together, just a—

Christine Bechtel, Vice President, National Partnership for Women & Families

Yes, that was my assumption, Jodi, which is why I didn’t try to totally rework it and just cut it out because we have a whole section, but I think when we see the next version where we’re asked to look at the whole document in context, I think that makes a lot of sense.

Paul Tang, Palo Alto Medical Foundation, Internist, VP & CMIO

But what I would do is argue the way Deven does. It says we don’t have just the privacy silo. We have privacy in a world and with all of the other things, so the minute we put right access, it seems like you always have to say, well, when you have a need to know.

Christine Bechtel, Vice President, National Partnership for Women & Families

Yes, the problem is, Paul, just it’s literally language problem. If you can figure out a way to make that apply to only one part of the sentence because the sentence covers patients, consumers, and providers, so I just couldn’t see my way to it, but I completely agree with you, and I think we can work on it offline.

Can I suggest, though, that I thought of three other concepts that I thought we should consider here, and these were inherent in the work that we did in the meaningful use workgroup which was meaningful use objectives should be achievable by a broad array of providers, but at the same time stimulating a significant progress toward improved healthcare. I have that in the version that I suggested. The second that I thought was inherent in our work was that fostering patient engagement and achieving meaningful use would accelerate progress toward the national priority goals, and the third was meaningful use objectives should enable substantial efficiency and innovation gains and reduce administrative burden. Those were concepts that I thought were sort of missing, and I wasn’t sure where we could put them in. I’m open to wordsmithing or suggestions, but just as concepts, I thought those three might be things to consider.

Paul Tang, Palo Alto Medical Foundation, Internist, VP & CMIO

I think those are lovely concepts, Christina. Other folks, and we can certainly look at the language you proposed and try to work that in.

W

I like that very much.

Deven McGraw, Director, Center for Democracy & Technology

Yes, I would agree with that. This is Deven. One way to avoid having privacy be considered to be siloed to its own section is to speak to it in the vision statement.

W

Yes, that’s really important ….

Deven McGraw, Director, Center for Democracy & Technology

And then you won’t necessarily have to feel like you’ve got to mention it at each and every opportunity to make the point that it flows throughout.

M

Great point.

Paul Tang, Palo Alto Medical Foundation, Internist, VP & CMIO

Great point. In fact, could that be, so protect information no matter where it resides or is accessed, is that something approximately like what we would want to put up there and make an overarching principle?

Christine Bechtel, Vice President, National Partnership for Women & Families

Yes, I think that’s a concept that you want to capture. I almost want to think more visionary that the trust is a foundation upon which this all works and appropriate protections for privacy and security that apply throughout the system are key to building and maintaining that trust.

Paul Tang, Palo Alto Medical Foundation, Internist, VP & CMIO

Okay, we’ll work that in.

Jim

This is Jim. I thought that was beautifully said, as much as we can preserve that language. I think that gets exactly what we want to say.

Paul Tang, Palo Alto Medical Foundation, Internist, VP & CMIO

And I like Christine’s addition there.

Jim

Yes.

Steven Stack, Chair ER Department, St. Joseph Hospital East

Paul, this is Steve Stack, and I like very much what Christine has proposed, both when she modified two and then those other additions. At an appropriate time, I’d like to make one more comment on principle number two.

Paul Tang, Palo Alto Medical Foundation, Internist, VP & CMIO

Any other comments on what Christine suggested? Okay, go ahead, Steve.

Steven Stack, Chair ER Department, St. Joseph Hospital East

I think Christine definitely improved that by deleting after the comma. I think as long as we’ve got privacy up at the top very clearly I think the right information at the right time implies correctness, appropriateness. It may not be as explicit, but it certainly implies it. I do think that this should be to improve individual and population health, the decision-makers, which includes patients and consumers, and I know that’s intended to be clarifying or additive, but certainly the people who are using this information who are considered to be the challenge at the moment are the providers or care. I’d almost have which includes providers and consumers, I guess, and drop the patient word that I advocated for on the last call so that it’s clear that both the providers and the people receiving the actual care both need it as opposed to having this be on the side of the patient or consumer side who needs the information to do their job.

Paul Tang, Palo Alto Medical Foundation, Internist, VP & CMIO

You’re right, Steve. The reason there was some parenthetical expressions was to say, well, the don’t always jump out, and we certainly made the point through our category on patient and family engagement that that’s what we intend, but you’re saying that decision-maker now might feel like it doesn’t include providers?

Steven Stack, Chair ER Department, St. Joseph Hospital East

Yes, I don’t feel excluded in that way. I just think it doesn’t, it just reads very much towards one side as if this statement then is intended exclusively to empower consumers or patients. I definitely want to empower them, but I think it would be more balanced if it said which includes providers and consumers.

W

Well, I agree with Christine. I agree with Steve, but for a slightly different reason which is that by not saying healthcare professionals or however we decide to say providers, I think the other way you read this is that that is the implicit decision-maker which doesn’t sit well with me for a wholly different reason. I think it’s a good idea to just say which includes patients and consumers as well as health professionals.

Paul Tang, Palo Alto Medical Foundation, Internist, VP & CMIO

Okay, so I’ve heard two suggestions. What they have in common is to add health professionals. Steve is proposing also to take out patients.

Steven Stack, Chair ER Department, St. Joseph Hospital East

I don’t care if you take it out or not. I was just trying to keep it in a few words so it was simple … lengthy.

Paul Tang, Palo Alto Medical Foundation, Internist, VP & CMIO

Okay, so the amendment is to add, is it okay with Christine’s word of health professionals?

Steven Stack, Chair ER Department, St. Joseph Hospital East

We’d much rather be called health professionals than providers.

Paul Tang, Palo Alto Medical Foundation, Internist, VP & CMIO

Okay, very good. Any comment on that? Okay, great additions. Anything else in principles? Then going to the strategic objectives, it talks about basically meeting the President’s goal, achieving meaningful use through the coordination of public and private resources (and it lists some of the ones that are covered under high tech), be able to through the … that the federal government has in high tech and other rule-making be able to align all these things together to address the national priorities set by the National Consensus Groups and to demonstrate how HIT enhances the goals in health outcomes and efficiency benefits. This is a bidirectional effort. It’s not just going up to data collection agencies, but also feeding back to the healthcare delivery system and that all the federal resources be coordinated to accomplish the goal.

Christine Bechtel, Vice President, National Partnership for Women & Families

Paul, it’s Christine. Can I jump in on number one?

Paul Tang, Palo Alto Medical Foundation, Internist, VP & CMIO

Sure.

Christine Bechtel, Vice President, National Partnership for Women & Families

Okay, so I had a couple of significant changes to this. I really still don’t love the capture concept, and I know that we talked a lot about this on the last call, so what I would suggest would be enable all Americans to benefit from the effective use of electronic health information to improve health and care by 2014. Those are two changes to the number one, and then I have changes to the bullets underneath it.

M

I think that’s much better.

M

I think it’s much better.

Christine Bechtel, Vice President, National Partnership for Women & Families

I’m just going to take that as a yes. Underneath, I really did not like just having sort of the single bullet about consumers and having it be really focused on sort of encouraging them to, it just does not, it sits fairly paternalistic to me and also implies that the way you’re going to get all Americans to benefit from effective use is through somehow consumer behavior change. What I would suggest is that the first sub bullet actually be focused on healthcare providers, and I focus my suggestion on that which we know consumers really want to see, and so that is encourage team-based coordinated healthcare across the entire health system. That’s sub bullet one, and then the second one would become support consumers in taking an active role in managing their health through effective access to and management of information.

M

Couldn’t be better said ….

W

I like the changes, but I would suggest that that consumer bullet not be a sub bullet. I don’t see why it is a sub bullet. It should be a major bullet. It should stand on equal footing with the others.

Christine Bechtel, Vice President, National Partnership for Women & Families

I like that even better. I think that’s right.

M

And maybe it’s enable consumers rather than encourage. That might help some with the ….

Christine Bechtel, Vice President, National Partnership for Women & Families

Yes, I said support, but same concept.

Paul Tang, Palo Alto Medical Foundation, Internist, VP & CMIO

Christine, this is Paul. I agree with the concept of support consumers, but why did you say encourage team-based healthcare. Why are we encouraging that as opposed to supporting it?

Christine Bechtel, Vice President, National Partnership for Women & Families

Fine, good, I just didn’t want to use the support word twice. Wordsmith away.

Paul Tang, Palo Alto Medical Foundation, Internist, VP & CMIO

I don’t mean to wordsmith it.

Christine Bechtel, Vice President, National Partnership for Women & Families

If I have my druthers, I would say drive it or accelerate it.

Paul Tang, Palo Alto Medical Foundation, Internist, VP & CMIO

I understand, but I’m thinking back to a comment that Marc Probst made earlier. Health IT, we really sort of enable policy, but we’re not policy itself. We can facilitate the policy change, but we don’t really make policy. In terms of we in the healthcare IT world, are you going to encourage team-based healthcare? I’m not sure we can do that. All we can really do is provide a structure that facilitates or supports it.

Jim

Paul, this is Jim.

Christine Bechtel, Vice President, National Partnership for Women & Families

I disagree.

Jim

I want to follow that and drive that back into the goal because the goal doesn’t reflect any awareness that process redesign, team-based care (but the process redesign is maybe as general as we could state it) is a critical part of this that if it doesn’t lead HIT design and adoption there won’t be any meaningful use, or it’ll be severely limited. I suspect that we aren’t going to address process redesign in this document, but I think it would make sense for us to acknowledge the need for it at least so that it doesn’t have the sound as if we’re going to improve healthcare by promoting adoption which is really the way it reads.

Paul Tang, Palo Alto Medical Foundation, Internist, VP & CMIO

Although the way Christine worded her one about team-based care, I think in—

Jim

What I’m suggesting is we drive it up into the goals so that, again, it’s kind of like putting privacy at the top so we don’t have to keep saying it.

Christine Bechtel, Vice President, National Partnership for Women & Families

Well, no. There’s a key difference here for me which is part of the purpose as I understand it of having kind of principles and objectives is that if there is an objective then ONC would be expected to have some strategies around how they will use Health IT policy to help make that happen, and it would be not limited to ONC. As we’ve talked about, it would be other federal agencies. Back to Paul’s Egerman’s point about encouraging team-based care, I actually disagree because it’s clear to me anyway that the meaningful use proposed regulation absolutely encourages team-based care by requiring providers in order to get incentives to begin talking to each other and sharing electronic health information.

Jim

Right, but what I’m saying is that the goal doesn’t say anything about that.

Christine Bechtel, Vice President, National Partnership for Women & Families

Right, but we - wait, the goal on meaningful use?

Jim

… goal.

Christine Bechtel, Vice President, National Partnership for Women & Families

I’m not sure. It’ll be in the vision. I don’t have any objection to editing the goal, but I don’t want to take it out of an objective or strategy.

Jim

No, I’m not saying take it out of the objective or strategy.

Christine Bechtel, Vice President, National Partnership for Women & Families

Okay.

Jim

What I’m saying is three years from now this will read like, didn’t those people know about process redesign?

Paul Tang, Palo Alto Medical Foundation, Internist, VP & CMIO

I don’t see that as a means …. The goal says improve health outcomes, patient engagement, care coordination, efficiency. Those are, in fact, goals, and yes, they may or may not require process redesign. They may or may not require this, that, and the other, but a lot of the things we think it may require is listed in some of the objectives, and I think the way that Christine labeled team-based care is a concept where you certainly can fit process redesign, and ….

Jim

But my concern is about that dependent clause that comes after the goals, Paul, by promoting the adoption and meaningful use of HIT, and anyone who’s tried to do that, I think there’s a growing and very strong consensus in the business that if, at least in your mind, what it says isn’t by promoting improved process design supported by adoption and meaningful use of Health IT, you don’t end up with any benefits, so I’m concerned about ….

Christine Bechtel, Vice President, National Partnership for Women & Families

But I think we’re trying to focus on the benefit which is going to require process redesign, but that is a given and an assumption I think here, so I think we focus on the end goal. In my mind it’s better to focus on the end goal and let folks do what they need to do to get there.

Carol

Yes, so I want to make a point about that in the objectives. I think that because this is the meaningful use theme, this another place to drill down on what are the meaningful use health goals that strategies will need to be developed around, and I don’t see that level of specificity here, and I think it’s essential because to just say we want people to benefit from HIT is great, but we also should establish what it is that the HIT is going, what are the health objectives that are going to be focused on. I would love to see those objectives tied here to the meaningful use theme.

Christine Bechtel, Vice President, National Partnership for Women & Families

I agree, and Paul, that reminds me of the achievable vision for 2015 and the fact that we still really need to take that up, and Carol’s got a good way to do it which is if you focus on hospital readmissions and med management you get out of where we were stuck in which was fewer heart attacks were sort of condition specific, but still something that is a little bit more tangible, so I like that suggestion very much.

Seth Pazinski, Special Assistant, ONC

This is Seth. I think one thing that we thought about with regards to the workflow redesign that really should be a strategy under the second objective. At least I think in our heads it was assumed, and we didn’t take the step of putting it here, so I don’t know if that addresses that piece of the conversation. Also, I really like the suggestion of sort of bringing in each of the components of meaningful use and making sure we have strategies to reach those health outcomes.

Paul Tang, Palo Alto Medical Foundation, Internist, VP & CMIO

Let me make sure we don’t, I want to keep track of the suggestions that have been made. So far I think we agreed to Christine’s rewording of number one. She had two more that she added. We agreed to move one. Let me go ahead and propose that we move both of the other two that she mentioned, the team-based care and the enable or support consumers to the high level, the numeric objective. … let me stop there and say are people in agreement with those two steps we’ve taken so far?

M

Yes.

Paul Tang, Palo Alto Medical Foundation, Internist, VP & CMIO

Then now we’re working on, then the notion of a means, process redesign. What Seth said is that ONC was … come in as part of the workforce training can come in to … a number of places, and that might be strategies. Is that okay with you, Jim, as far as that sort of living in the strategies area which we haven’t done yet?

Jim

No, I would say it’s a first principle, and it probably accounts for more waste and unmeaningful use of HIT than any other single factor. I think it belongs in principles.

Christine Bechtel, Vice President, National Partnership for Women & Families

Paul, what I heard Carol say was once you’ve moved the two sub bullets on team-based care and consumers out and made them actual numbers that the sub bullet might be replaced with some more specific health goals, the sort of reducing hospital readmissions so that you could say something like enable all Americans to benefit from the effective use of health information to improve health and healthcare by 2014, including by, you know, reducing hospital readmissions, improving medication management.

Paul Tang, Palo Alto Medical Foundation, Internist, VP & CMIO

Right. I hadn’t got to those. Sorry, I was trying to address each person’s—

Christine Bechtel, Vice President, National Partnership for Women & Families

Sorry.

Paul Tang, Palo Alto Medical Foundation, Internist, VP & CMIO

—suggestion …. Let me get people’s reaction to Jim’s point of moving process redesign into the principles.

Jim

It would just say something like process redesign is a necessary precondition for meaningful use of HIT.

Paul Tang, Palo Alto Medical Foundation, Internist, VP & CMIO

I personally am feeling that’s a bit prescriptive. I take your point—

Jim

Okay, ….

Paul Tang, Palo Alto Medical Foundation, Internist, VP & CMIO

I take your point that that’s important. It feels prescriptive to me, and what do other people think?

Jim

I would say it’s empirical, but that’s—

Christine Bechtel, Vice President, National Partnership for Women & Families

But to Seth’s point, isn’t it covered under number two because that is a big part of the work of the regional extension centers and the workforce training and the efforts of other federal partners? I know … is doing support for community health centers and process redesign. It’s sort of inherent in the programmatic aspects.

Art Davidson, Director, Public Health Informatics at Denver Public Health

This is Art. I agree with Christine that in our environment we look at that as a major piece of the wreck. I was looking at the last sub bullet under that strategies, and I thought we could just insert the words promote process redesign and development of products and tools to focus on usability for end users.


So, protect information no matter where it resides or is accessed, is that something approximately like what we would want to put up there in the principal?

Yes, I mean, I think that is a concept that he would want to Chat.

Capture, but I almost think and more visionary that the trust is a foundation upon which this all works, and apart. Protections for privacy and security, that applies throughout the system, are key to building and maintaining that trust.

Okay. We will work that in.

This is Jim. I thought that was beautiful as much as we didn't deserve that language, I think that is exactly --

And I like Christine's additions there.

Paul, this is Steve. I liked very much what Christine has proposed, told what to modified to and the other editions. And at the appropriate time of like to make another edition on principal Robert too.

Any other comments on what Christine suggested?

Go ahead Steve.

Thank Christine definitely approved that by deleting after that.

As long as we get privacy at the top very clearly, I think at the right time apprised correctness and appropriateness. I do think [indiscernible] decision makers which includes patience and consumers, and I know that is intended to be clarifying or additive, but certainly people that are using this information that are considered to be the challenge at the moment are the providers of care. So I would almost say include providers and consumers and drop the patient care, so it is clear that both the providers and people receiving the care both need it as opposed to just having people on the consumer side getting information about doing their job.

Steve, if you are right. Their reason there was some parenthetical expressions is, because they don't always jump out and we have certainly they are impact on decision making to save it decision makers now doesn't feel like it includes providers.

And I don't feel excluded, but it meets to one side [indiscernible] exclusively against our consumers and missions, which I definitely want to empower them but I think it would be more balanced.

I agree with Christine and Stephen but for a slightly different reason, which is by not saying health care professionals or however we decide to stay providers, I think the other way we read this would be the implicit decision maker which doesn't sit well with me for a wholly different reason, so I think it is a good idea to say which includes patience and consumers as well as health professionals, block etc.

Well what I have heard --

I don't care if you take it out, I was just trying to keep the two words so it was simple and not so lengthy.

So the amendment was two attic, and is it okay --

I think we would rather have it called health professionals and providers.

Okay, very good. Anything else in the principles?

Okay. But then going to the strategic objectives, I talks about -- it talks about meeting the president's goal, achieving meaningful use through the coordination of public and private resources, and it lists some of the once covered under high tech. And be able to, under the [indiscernible] that the federal government has in high-tech and other rulemaking, be able to align all of these things get their to address the national priorities by the national consensus groups, and to demonstrate how but HIT improves -- work enhances the direction of efforts. This is not just going out to data collection agencies but also feeding back to the health care delivery systems.

And then, all of the federal resources be coordinated to accomplish the goal.

Christine, can I jump in on north one?

I had a couple of significant changes to this. I still don't love the capture concept and I know we talked about this on last call, so what I would suggest would be to enable all Americans to benefit from the effective use of electronic health information to improve health and care by 2014. So those are two changes to the number one and that I have changes to the police underneath it.

I think that is much better.

I will take that as a yes.

Underneath, I didn't like a solid as consumers and encouraging them, and it is fairly paternalistic to me and it also implies that the way you are going to get all Americans to benefit from the effective use is through somehow consumer behavior change. So what I would suggest is that the first sub bullet actually be focus on health-care providers, and I focused my suggestion on that which we know consumers really wanted to see, and that is, interest team based, coordinated health care across the entire health system. That is bullet one, and the second one would be to support consumers in taking an active role in managing their health and access to and management of information.

Couldn't be better said.

I like changes, but of its suggest that the consumer bullet not be a sub bullet. It should be a major bullet and it should stand on equal footing with the others.

I like that even better, I think that is right.

Eighty is enable consumers.

I said support, but same concept.

This is Paul. I agree with the concept of support cancerous, but why would you say encouraged based health-care?

I just wanted to use the support or twice. If I had my druthers, I would say derided for accelerated.

I understand, but I am thinking back to the comment that Mark probes made earlier. [indiscernible] enables policies, but we are not policy itself. We facilitate the policy but we don't really make the policy. And we in the health-care technology world are on to encourage health care. We might just provide a facility that supports that.

Well I will try that back into the goal. Because there is it says, the school does not reflect any awareness at process redesign based care. The process redesign is maybe general, but it is a critical part of this and if it does not lead HIT design and adoption, it will be fairly limited. I suspect that we will not address process redesign in this document, but I think it would make sense for us to acknowledge the need for it, at least, so that it doesn't have the sound as if we're on to improve health care by promoting adoption.

Although the way that Christine worded her one about team based care, I think that in --

I suggest we drive it up into the goals. Again, like putting privacy at the top.

Well know that there is a key difference here to me which was part of the purpose that I can understand of having these kind of principles and objectives, and if this is an objective, then ONC would be expected to have some strategies around how they would use HIT policy to help make that happen, and it would not be limited to ONC, it would be other federal agencies.

So back to Paul's point of encouraging team based care, I actually disagree because it is clear to me that the proposed legislation encouraged it by requiring providers to start talking to each other ensuring electronic health information.

But what I am saying is the gold doesn't say anything about that.

The goal on meaningful use?

[indiscernible] goal.

Well, I am not sure. It will be in the vision, but I don't have any objection to F-15 the goal, but I don't want to take it out of an objective or strategy.

I'm not saying to take it on of the objective were strategy. [speaker/audio faint and unclear]

I almost see that as a means. Because it says health care ordination and efficiency, those are in fact goals, and yes, they may or may not require process redesign for this that were the other, but a lot of the things we think it be required is listed in some of the objectives, and I think that the way Christine labeled team based care is a concept we can certainly fit processed through design.

[speaker/audio faint and unclear] promoting ONC, I wonder who is trying to do that. -- promoting HIT, I wonder who is trying to do that. At least if in your mind it says, by promoting process design supported by the adoption as meaningful use less HIT, which don't end up with any benefits.

Fight think we're trying to focus of a benefit which will retire process redesign, but that is a given and an assumption here. So I think the focus on the into gold -- in my mind, if it is better to focus on the handle and let people focus on what they need to do to get there.

I wanted to make a point about that in the objectives. I think that because this is the meaningful use, we need to drill down on what are the meaningful use schools that strategies need to be developed around, and I don't see that level of specificity here. And I think it is essential to just say, just because we want people to benefit from HIT is great, but we also should establish what it is that the HIT will be focused on. And I look like to see those objectives tide here to the meaningful use.

That falls under that achievable vision for 2015, and and that is still something that is tangible, so I like that very much.

I think one thing that we talk about regarding the work flow was, that really should be a strategy under the second objective, or I think in our heads it was assumed that we took a step in putting in here, so I'd think we address that piece of the information and I really liked the suggestion of bringing in each of the components of meaningful use and making sure that we have strategies to reach those held out comes.

Let me make sure that we want to take -- we need to keep track of the suggestions that have been made. So far, I think we agreed to Christine's rewording of number one. And she had two more that she added, and let me go ahead and propose that she moved the other two that we mentioned, the team based care and enable and support consumers to the high level numeric objectives, and let me stop there and say, for people in agreement with those two steps that we have taken so far?

And then, the notion of means, for process redesign, what that says is that ONC has taken that and that could come in as training in a number of places and that could be strategies, and is that okay with you, Jim, as far as living in the strategy area, which we haven't done yet?

I would say [speaker/audio faint and unclear] more meaningful use of HIT than anything. I think if [indiscernible] the principal.

Paul, what I heard Carol say was, once we have moved the two sub bullets on the based care and consumer is out and made them actual numbers, that the sub bullet bite be replaced with more specific health goals, reducing hostelry admissions so you could say something like, and able Americans to benefit from the effective use of health information to improve health and health care by 2013, including by reducing hospitalizations, removing medication management, etc.

Right, I hadn't gotten to that, I was trying to address each suggestion at a time. So let me get people's reaction to Jim's point of mending process redesign into the principals.

If we just said process redesign -- [indiscernible] for meeting.

I personally feel that is a prescriptive. I take your point that that is important, but it feels prescriptive to me, what do other people think?

I would say it is empirical.

But two set this point, isn't it covered under number two? Because that is covered under the regional training centers and work-force training and other federal partners. I no [indiscernible] is doing process redesign, it is sort of inherent in the programmatic aspects.

I agree with Christine. In our environment, we look at that as a major piece of the requisition.

I was looking at the first sub bullet under the strategies and I was thinking we could [indiscernible] process redesign and promote products and tools for usability under users.

Where was that?

I changed the numbering because I have been keeping space on all of the good comments, but under the one where it says it, Regional Convention Center, the open bullet, the last of those open circles is, promote process redesign and development of process and tools for feasibility. I think that is embedded in the concept of meaningful use. I agree with Jim. It is everywhere, that it is and means.

I think that Phil is right.

I would say that HIT is a means-care process define, and that is the issue. But I am happy to go with the consensus.

I think am hearing people put it more in the strategy and Means kind of area, is that a fair assessment?

This is Janet. I take Roger had a good suggestion to put it in the process and redesign of Project tools to focus on feasibility. For that particular one.

Okay.

And the next comment was from Carroll on the more specific health goals. And I think we have heard different suggestions on the different areas to put it in, and let's make some progress there on terms of where we think we should insert that.

This is Christine. And I have looked at as far as the bullets under number one.

So to benefit from the effective use?

Yes, adding [indiscernible] to provide care by 2013 including reducing hospital admissions and improving medication management, we should have care coordination in there, things like that. Preventative care.

So would you say including? Including means, it must have. Such as beans, these are examples. Which do think we are talking about?

I personally think it is including, because I think we have to focus. That was part of what I liked about the [indiscernible] addition although people said it was too specific, it doesn't focus and therefore some accountability for driving those things and fish along with what CMS is proposing in the nucleus, where you have -- you could even put sort of that smoking Station, avoidable [indiscernible] with the elderly and you could put some of that in there as well. But we should have a way to focus the use of technology on the types of activity that matter and I think it is sort of including. I think it is definitely and including but not a such as. That is my perspective.

Other views?

Well, as you defined it, Paul, I prefer a more permissive it, such as, because, unlike a list of things that I just rattled off are very good. And I believe he will find that problems are not -- if we have the technology to track white people are being admitted to hospitals unexpectedly New York, and they are not stopping cigarette use and things like that, you may find it is not something that technology itself is able to help or fix or manage information better to prepare for other socio-economic reasons that are big drivers. So I almost think it has to be a such as, because we have not yet on the study, and we don't know the answers to say what including means and that is presupposing the answer that we do not have yet.

And a doubtfully disagree with Christina in principle, it is just, and she defined her words including such as, iTunes prefer the terminology of such jazz.

I am just -- but with to prioritize rather than a global statement, so it could be that we are feeling the purpose of it different, but I was thinking of part of the purpose of this strategic plan to be to repair ties resources and the placement of those resources, so that could be called for a little bit more specificity than permissiveness, for the broad principle statement document is [audio interference] value, it would be more permissible.

What about with emphasis on, or focusing on?

That is good. And the area is specified by the rule.

Or can of the IT strategic objective -- we already said one of our principles should focus on Health Properties specifically identify the health priorities of the time. And so ONC works to develop specific strategy is to address those National Health parties. Do you see what I'm saying? It says, if you must be specific, and perhaps that is where the meaningful use measures come in, but it doesn't pan and down as a strategic objective until you do the following. And I'm getting closer?

ONC doesn't stop and implement all of the parties. That is one input to their establishing things like, [indiscernible] meaningful use. And I think it is important for them to specify which areas they are on to focus on, and which strategies they are going to develop to achieve those objectives.

A think that is what I am saying. The objective is that they do identify falling debt National Health. Measures and focus in that area. And I think that plan identifies what the hell's -- identifies what the health priorities are.

Well when we determine what benefits get paid, those measures that need to be benefited in order to receive the funds, you are pretty much the priorities.

Well, I agree. And I think it should. And I am thinking it potentially complies for the strategic plan itself. And that is supposed to reference in the National Party.

This is a section on meaningful use, and two carols point that we do have many police objectives, they are putting a stake in the ground as far as significant priorities that were played on the table. And I think that we could mention those by those that are identified in the proposed legislation that could come down the pike in the next five years, they could prepare as well.

So I'd think that your point is taken, there is already a stake in the ground as far as meaningful use objective is as to what those priorities are, and maybe we could referenced Those,.

Don't they also update the Plan annually?

No.

I thought you did and as a lot. I thought that coordinator had to do an update annually? I will check it out, but if that is the case, they would have another opportunity to update and show the plan to them and that would be specific from year to year. I will take a peek.

This is Janet. I think this priority issue is one for which we can craft language. It makes sense that the ONC has identified an additional set of priorities dealing with existing priorities as promulgated by private partnership groups, and then just have language that a bank established as part is that these will need to be aligned with those on board. Because the house and the Senate bill calls direct the Secretary to establish priorities [indiscernible] with the upset secondary standards group, so the chance is there that by the Tennessee is the light of day, we will have hopefully a directive to establish and as secretary to put a stake in the ground and establish a priority.

Judy, back to your summary, I think that was an excellent way of stating what this needs to be. It is in meaningful use section and you do have a stake in the ground, and it would be great to put a stake in the crowd at but the door open that says, they will leave that open, but there are priorities articulated very clearly in what will be required to achieve meaningful use and put them here.

I am seeing still a little difference between Janet and what you just summarized, Carol.

This is Janet. I didn't see any difference, I think that is fine. Whether it is in a one page appendix or in the section where we position it, the meaningful use parties and majors are based on but the [indiscernible] parties. So it doesn't matter to me who you call them out as, there are disparities that have been increased by ONC and captured in meaningful use majors, and the basic principle here is that this work should be directed at achieving, instead of national priorities and goals as for their party is are promulgated, it should be aligned with that.

That I understood. Does that mean that specific parties would be put in the strategic objective?

I need to have to organize the meaningful is measures are gripped by priority area. So I think one is left to explain how one got to the meaningful used measure, which was the start of the specific priority areas. And that is already listed in the background of that document.

I think the objective is the time to say, these are our specific objectives, within that context.

So it lists every major?

No, not every major. Back to the thing that Jodie and I were trying to summarize. In the meaningful use section, is it necessary to read dates since we already stated it in the Vision section that health priorities will be developed in the context of the national priorities cracks in that context, there needs to be specific objectives meaning not every national partnership abjective, they are a subset that are now articulate it in the meaningful use regulation, that ONC has a stake in the ground on, and this is the section that states' those specific objectives. That is what I am proposing.

Let me see how you would recognize this. It is nice -- let's talk about two years from now and it will it up to it. The tests would be if we live up to addressing the national priorities. That is one way to look at it and that is a way that Janet's language went, purses, to we live up to specific blood pressure control. Sell an example, there is an NCRN, comments come up, and pretend this -- there is the defensive on the back of the outcome would change in this particular area, and with listing specific measures versus listing that we followed the secretary or HHS or limited national parties [indiscernible]

Paul, I doubt that anyone is proposing listing specific measures, but I am proposing is listing specific objectives. Measures can and should change.

Carol, what are your objectives? Can you give us examples.

I am confused about how that differs from the National priorities and goals.

There are ones that, as a result of the meaningful use goals and meaningfully is measures are the health objective before the ARRA fund paying, and we have gone over them a couple of times. Management and reducing admission rates, a lot of things are what the requirements for meaningful use will hinge on.

Pour Those -- those are one in the same. You don't have to include all of them, maybe you just want to include examples and kind of group them? Because what I envisioned was, we have a national priority as care coordination, and within that cannot we have specific measures to the dedication of Management and sharing admission and. Mission rates, which is indicative of per ton of copper. Handoff. So I find that important to a group them according to that. Unclear kind of talking about the same thing.

Right.

Up okay. We will make our best attempt at coming up with the language that reflects both of those perspectives. And we can refine it later.

Any other comments.

I think I have exhausted the comments that have been put forward so far in terms of the actions.

Okay. We are still doing pretty well on our schedule. Now we are moving to the number two. Jodie, do you want to walk us through a very high level on the goals and principal?

Sure. This is the policy and infrastructure, we will start with the goals and principles and then get into the objectives including enabling health electronic [speaker/audio faint and unclear] technical help specifications, and then have six principles that have been identified, having specifications required or promoted by the federal government that at a minimum allow [indiscernible] coordinating federal resources on activities, that the federal government should leverage wed and market innovations and [indiscernible] exchanges and that effective information exchange should enable [indiscernible] Exchange and the exchange should contribute to improvement of health and health care and the specification should be as simple as possible. And that the health information specifications should promote patient education and access.

The first thing that I wanted to raise ticket the context at the school level, this was something that came up in the comments. In looking at this team, less of it was very focused on health information exchange, and yet, the theme is called [indiscernible] infrastructure is broader. And the question is, do we have the right goal and approach here, should this be focused on electronic health information exchange or is this the broader than just health Information Exchange?

Give me an example of what you think is left out with stating the goal or exchange? And this was a comment that came and from somebody on the workers. The question was whether or not there are other policies or technical infrastructure is in place that we should be talking about beyond just the exchange component, so the technology itself, for other policy infrastructure that needs to be in place that doesn't necessarily go to exchange?

For example, hold harmless, some of the antitrust provisions, reliability issues related to data prominence and once did it is Exchange, who does what with it.

A think the problem comes in the ambiguity of the term health information exchange. And if one somehow T-notes the notion of communication of our transmission of information between two individuals or organizations, or someone pushes that out into something a bit more concrete that they think it's very general, all of the things that Patti mentioned just kind of fall into place. It is just awful amount versus vervet problem with the exchange.

-- just the whole noun versus verb problems with the exchange.

I thought double that supports -- that supports all of the things that will be alluded to later.

A think that helps expanded like Christie was talking about.

What I am hearing is, basically including information management as well as meet the kind of reworking electronic health information exchange?

Right.

This is Patty. The only problem I have with inserting management is that it actually adds to or at least preserves in tensions between institutions the subject systems and Exchange banana afterthought prisses free flow of Health Data and institutions being an instance. And maybe in a 3 to five-year Health window that is okay, but putting that that can we sort of Delegates vendor approach to the institution system.

This is Chris again. Normally I am extremely synthetic to that viewpoint and come from the same philosophical perspective. ITunes if we are going to talk about the kind of standards and things listed under objectives and strategies, by its very nature we have to talk about management, unfortunately. So I agree that it is hopefully a near-term goal, but I don't think we can take exception to how it is generated and stored.

Jody, as your group is working, if you could find a way two at least at some point figure out whether we need to be explicit about whether we are talking about a transitional approach that is growing to a new model based on our old model, or a seat change in terms of management, I don't have a way to fix it right now, but I don't want to lock us into vendors building sickle point bridges between hospitals and Industry data exchange.

This is Devon. I think this is a place where -- and I don't have any brilliant wording that I can suggest here, but this section is deemed is sort of where some of the technical specifications and our overarching principles about what the technology should do and how detailed the specifications need to be has to reside. But at a minimum, it needs to start with a cool about, that is a little more aspirational, again, and maybe the next two why we are doing this in the first place. In the same way that some of the other goals to like meaningful use. This is about harnessing the technology and putting in place sorter, specifications that are needed to enable the technology to be used to facilitate improvements and health outcomes.

I mean, again, I haven't perfected any language here, but it is sort of a bit of a narrowing -- a pretty narrow language to be satisfactory for an overarching goal.

And especially, there are some objectives and strategies that I did our arguably going beyond what that goal is.

I wonder if it could be as simple as reversing some of the border? How about, enabling the management and exchange of Health Information? And all of a sudden, the noun-verbal thing is blurred?

Paul, I like that.

Another alternative would be, enabling the electronic Health Information [audio interference] for all of that.

They can't use what they don't have.

This is Paul. I don't have any problem with managed in an exchange, but I need you need to keep the word exchanging here, only because ARRA does make a big point out of Interoperability.

Right, it might be through the development and support of the proposed policies.

And to Devon's point, the first principle talks about any specifications alone providers to achieve meaningful use, so it does take back to this first theme, with all of the ties to the health goals, etc. So I am wondering between the goal and the principle, if we are getting there and that is something more than necessary?

This is Patty. I just wanted to be sure -- and I don't see this in the objectives for strategy's yet, but we leave a little bit of room for unexpected and perverse players.

[laughter]

I was just laughing because that is so true. We do have a lot of perverse players. Are you advocating for perversity or against it?

[laughter] I wasn't legally and one on the call, but if you have anyone from those groups -- we do have two recognize that this the best addressed to [indiscernible] or the clinic record that some has to be integrated back into the hospital, breathe and the home based center that has to be pulled in. So it speaks to me, kind of the well known and well understood HIT products, we know that industry as well as the boundaries.

Although you do have principle number five.

And that calls out of, all participants.

Well I think at some point, it might be useful to take this back into the perverse players community, like an atom bomb is worth or. Newburg and get a sense as to where they see themselves-like with Adam Bosworth or Peter Newburg, and I'd think we have two recognize that data flows in and out of cable network channel systems and somehow, that has to be under this infrastructure, even if it is labeled.

(Captioners transitioning at this time).

This is David. I'm not sure I'm exactly following the point. What is your concern? We need to be more explicit about the number of non-traditional places where the data could flow?

I'm wondering when we get to the discussion of the objectives that we might need to think about additional objectives that get to Patty's point ago a duty that we look at the objectives they [Indiscernible] been in for use in a jar products and to dump it to the broader scope. I'm not sure that they go as we're talking about it right now would be problematic for would not include those perverse [Indiscernible] as describing them. I do think there's probably room to talk in the objectives and making sure we have objectives that go to some of the other players.

I wonder if you want to move to objectives to check our work in a sense sort of like what Patty was suggesting. And put on some different filters and see what it applied to some of these other constituents.

Go ahead.

Before we move, this is Chris. I have a couple my comments on principles.

Of it's going to ask before I move on.

Number three, the phrase the web, that kind of bugs me. At a minimum we ought to replace the web with something like the public Internet open standards, and market innovation. At the same time, I still don't understand what the comment is about perverse players would like to understand it better. I think there is communication that's going to happen on things that are not the public Internet that may for instance be the phone network. We should include it.

You are getting my idea about the perverse, unexpected players in the Health IT environment. And it may be that different communication channels if we change radiofrequency our end up with a different kind of management of a radio or it may be different companies like Microsoft [Indiscernible] -- I agree with your expansion from the public Internet -- from the web -- I think we have to do with can either ignore them but we have to say they must look like Health IT vendors. It's going to be maybe the best thing we can do and the principle is still along with what was said earlier, about maintaining currency within and alignment with emerging trends. In communications and inflammation technologies. Are having a principle that requires us to evaluate the appropriateness of the regulation.

I think that's great, so then I would edit No. 5 which was another, I had which I like the first part about simple as possible. Designed for implementation by all participants is also good, feel like we ought to add something like enables or encourages or allows for future innovation and evolution.

I think we need something that says we don't want to freeze this in amber and say we just want to put specks that relate to things that are popular at circuit to the US and age, 2009 to go that's what we are aimed at. To allow for innovation.

Maybe I can incorporate that bought into a revision to number three using the reverse order approach. So the federal government should leverage innovations and the market and information and communication technology to foster.

I love it.

I like it.

The federal government should leverage innovations, should leverage market innovations in animation and communications technology to foster appropriate health information exchange. So that's basically opens up innovation without trying to put specific levels.

Did I hear you say Foster market?

No should leverage innovations in information and communication technology.

[Indiscernible] in terms of some of the directions around overall economic stimulus, it's possible that permissive language here could actually stimulate industrial investment and new jobs.

So the conversation, sorry. Of.

What is the restrictive language? This is David. I certainly encourage all of the sentiment here, I'm just not quite clear what language we are stumbling on. I agree with the change the web to something different. Where are we locked into the current world view by what's written?

Beyond the web, and, this is Deb. I don't know if it's specifically which people repression on but just a sense that there needed to be a greater emphasis on the innovation point. It's not as though anything jump out as being Clementine except for the web term which clearly is a specific thing. But more I think this is an important point the only mention that in there now is -- hold on, I'm losing my place on the document. I think it's under emphasized. It's not that anything specific in here but since this isn't written in stone, is there anything David, that troubles you about this language?

No, I was pleased that was generic about information exchange. It does not use language like [Indiscernible] or anything--

At least not until later.

We have issues with . this one seems fairly open. I was afraid I was missing something and it's still early in the morning for me. Maybe I'm just not awake. I'm sympathetic with an able and new ways to do this. I didn't see what was the stumbling block. I just wanted to understand what I was missing . I like the changes that were suggested by Paul.

David, this is Chris. I the explicitly my thing I was interested in is I think phone technologies are not explicitly recognized and other mobile kinds of things and a number five where it says we want to decide for implementation by all participants. I think there is some tension of how much innovation do you about any set of standards or they want to encourage and said standards. As we've seen other places there's a tension between topologies that exist today that are not seen as universally sufficient. The least they are understood.

I guess I certainly agree with that. My concern would be that if it's hard for me to parse these subtle meetings as an insider, then the outsiders are certainly not going to parse them. We need to be explicit.

Guilty as charged.

And ask one thing on this one is that I think the concept of the Web understanding the best, was that there be mechanisms that it advantage of the public communications, options and not as proprietary network to go to read want to make sure we talk about leveraging public technologies that are widespread and publicly available?

Yes, I think we should.

This is Paul. One of the things I should point out is most of these principles actually reflected wording in the document that [Indiscernible] implementation workgroup came out with. So we took a lot of those sentences and reworked them a little bit. And I think the web was one of the things they called out. It did arise from hearings where they have these people from Adam and [Indiscernible] come and -- that's where it came from. [Indiscernible] this is David. I agree with Jody's prior comments about public Internet and sentiments like that. I would point out that you can have a completely private exchange on the public Internet. If the issue is control and access, then maybe we should call those issues out. You cannot create an implicit public control by same public Internet because I can create a private network and a completely invisible to even though I'm on the public Internet. I do know what's really at stake here. Is it about the control of this information? Or is it about the channel somehow?

I think we might need to move on because I think we might be guilty of over reading these words.

I think it was just the principle was we're going to use the Internet. Very simple thing

Of reuse information and to medication to colleges and it doesn't eliminate everybody?

We don't need to build something new law, in other words.

Right.

This crisp COAT the only of the word [Indiscernible] this phase of an open standards somewhere on number three.

Yes, thank you I'd like to see that stay in.

Whether other comments on principles or additions or concerns about any principles here?

This is art. I have one question go back up on the meaningful use. We talked about the public private sector efforts to coordinate and harmonized to reduce the burden on providers. In this section on principles, you have in number to [Indiscernible] across federal resources, but I don't know where or if there's a need to call that out about the public private coordination to avoid conflict.

Does that make that concept elevated to an overall or overwriting getting principal? It seems like a pretty decent concept. Restated from the they won its public and private-sector efforts to improve [Indiscernible] to announce -- so the concept was that public and private efforts be coordinated in a harmonized to reduce the burden of providers and consumers.

Yes, I think that should fall forward.

Of that concept up as a [Indiscernible] principle as opposed to having a [Indiscernible].

Right. It seems like it applies everywhere.

And is well stated in the statute.

So we are protecting information everywhere [Indiscernible] and we are making it less burdensome for everybody. Those are nice.

Any other comments on the principles before we moved to the objective?

Okay. Great. Let's move to objectives. I'm going to recommend to the time the we focus on the five number of objectives and not get the letters unless there's some major concern of folks want to move one of them up by level or something like that so that we have at least some consensus on the objectives of themselves within getting detail on strategies.

So we have now just briefly the first is about enabling exchange by adopting [Indiscernible] and implementations position the second is insured Health IT products or interoperable and establish a petition criteria is of all adopted exchange standards. [Indiscernible] of Care Improvement, the for this increase in the nationwide capability for health information exchange and the fifth is building confidence and trust and held a commission exchange was making participation is shared [Indiscernible] for policies. Let's talk about these objectives first and see if folks have comments on the objectives and if there are things in light of our conversation of the goal and three scoping of the call that needs to be modified, added, etc.

This is Devon. One thing that occurs to me is that there seems to be a strong focus on technical standards that's not even necessarily reflected in the overarching structure for the certification criteria. That are in the eye as far where technical standards are adopted in some cases. Technical functionalities play a stronger rule and I think that the way we structure this objectives should be consistent with the IFR at the minimum. Functionality is one thing but a specific technical standards and whether one is needed are not is another question. Some I didn't understand what you just said.

I think the way that the wording is, the way that these objectives are worded puts the adoption of standards and implementation specifications as a very specific objective. When what I liked about the certification criteria that were released in the IFR was that there was very careful consideration of when you needed to have criteria that systems needed to need in terms of technical functionality. But that was not always a specific technical standard. And in rare cases where implementation specifications which are always at a sometimes excruciating level of detail -- there was a very careful we are growing this movement into a place where maybe some more specificity down the road, stage two, [Indiscernible] but also with respect to how regimented we are with respect to technical standards. I just thought that the IFR had a graduated approach to getting to more levels of specificity that isn't necessarily reflected in these objectives.

So that's more an incremental approach. The IFR does have the things listed here.

That's right, but it does not always adopt a specific technical standard or implementation specifications for every area where there's a technical functionality that's made it. And I just think that it's not merely word smith in, there's a very, a building. That's in place that's not necessarily reflected in these objectives.

Would that be in the principles?

I think it needs to be reflected in the objectives as well. Unable exchange by adopting standards and related implementation specification and data dictionaries. Yes, but--

Maybe you want to add the word in a mental somewhere.

Is and that we are talking about? Wore an incremental approach?

I think maybe the distinction is between specifying a functional spec and a policy rather than a technical standard. Under the assumption that the policy and a functional behavior is what stays constant although the standards evolve. Is that where you are headed?

Yes, this is Carol. I'm agreeing with that because that's exactly what I think Kevin is trying to sell. Sometimes these things are achieved through a technical specification a technical standard. Sometimes there achieved through a typical policy which says you need to achieve this kind of an outcome. You need to be able to audit records and keep these tend fields for one year. That's not necessarily a technical standard person, a technical specification but a technical policy.

I think the head of privacy and security is just the rule model for that or they don't specify any standards, but it is specified policies that you have to make a go.

So the issue is what's written for one or two. It's not wrong, it's just want a new thing called, I don't know--


[Overlapping speakers]

I'm looking at one and two and M LaChance to the conversation. Is there an objective that goes over this about identifying and developing policy on a puppet technical specifications and functionality and technical policies [Indiscernible] what ever the two is. And then maybe one and Two are really strategies for during that and maybe you have [Indiscernible] qualifier in there where appropriate by something like that to say there are different strategies for meeting that. Sometimes it's standard sometimes it's technical policy, sometimes the implementations, up sometime certification, sometimes maybe all of them.

And I tried to St. Devon comment and at the same time perhaps clumping some of these objectives? So reducing 523 objectives. It may start out with something closer to number four which is increase the nationwide capability to exchange health information through appropriate policies and technical standards. I believe that leaves with the concept that Devon talks about.

Then I entered. Isn't that pretty much restating the goal? Of the whole theme?

Well, you are exactly right. Let me see the of the two and maybe we take some away our maybe it's worth it. The other 21 is to establish the appropriate technical standard for an interoperability and to to increase confidence in interoperability through certification. I guess one is to lead with the notion that there is a way to increase the nationwide capability for exchanging help and formation. And its through appropriate policies and technical standards. That was Devon is point. And you are right it mirrors.. And then there's a couple other things that addresses the actual need for technical standards in some areas. And a way of improving the confidence in the system through certification.

This is Paul. Those are interesting comments, but I don't see how certification increases confidence.

I was trying to mimic the No. 3 which is the increase the market confidence. And a lot of that has to do with the certification process so that how I got that.

Because the reason I say that to do this right from a standpoint of exchange, which written here for one and two is correct. The government has to adopt standards and the government has to adopt basically certification criteria surrounding those standards. That's how you are going to get Exchange. You put a lump those two together. One and two you could make that one concept that you adopt the standards and you are going to establish certification criteria for the exchange standards. But that by itself in my opinion it doesn't necessarily increase confidence.

You are saying there is a need for a third objective meaning the confidence? Yes.

I think so. I've lost count -- what are the other two, Paul?

Reading from the original, one is about standards, to have a certification criteria for those, three yours say there are other ways of increasing the market confidence and Ford, they have finished likability and five, the confidence and information exchange.

I certainly agree when you get to three and 5 I get confused. Maybe one way to think about grouping these things is you take what currently written as one and two which is the adoption and certification and say that's the technical stuff. And we take the sentences and a group them together. That perhaps we have some sentence that tried to reflect the earlier discussion about policies and the incremental approach to advance ourselves towards exchange. And then you have a third thing that is around confidence.

This is Jim. Three is largely redundant of two. It would be almost restates to. So there probably is an opportunity to fold three into two and make that more clear.

This is Chris COAT I had heartburn with No. 2 and maybe deflating it solves the problem. The idea is I think you could interpreted -- it's the word all is a problem and the idea of product interoperability. There's a viewpoint that says that the products made to be certified on a wide range of things, all the way down to the core of the product some of which certification has nothing to do with interoperability except for very tangentially. I think the policy needs to make sure that we have systems that interoperate with the exchange, not necessarily product to product interoperability. My concern is people are going to confuse that if we are not clear about this language.

This is Paul. I disagree with that statement. Many because if you look at the [Indiscernible] one of the really great things about the IFR is it talks about modular products. The idea that consumers and providers can purchase their products from multiple sources. You need to have product to product interoperability for that to occur. That activates one of the most exciting parts of the IFR to go I did have a phone call with one of these people [Indiscernible] perverse but and there were all excited about that.

I think the IFR is great. I think it went in the right direction, I just don't think this language is as good as the IFR stuff and I think it's the responsibility of individual artists to make sure the pieces conform with each other.

That's where we are right now . It's like almost impossible to do. There's a clear need for the government to step in and the government has with the IFR.

That deserves a further discussion that I want to belabor here. I think we may very well be on the same page. But I think we do have a problem if we are asking the federal government to be responsible for processes for enterprise a decoration. I just think we won't succeed with anything.

This is Pat it. I appreciate the sentiment being expressed and I think criteria certification criteria for exchange standards alone is insufficient. So it's probably the way it's stated, [Indiscernible] a brand identification Code but I am saying to restrict the certification to the exchange standards and not to any of the standards seems odd to me.

This is Paul. I agree. It's not by itself sufficient for exchange, but it's one component that important to do. A series of strategies and objectives and this should be at least one of them.

Can I suggest maybe -- and tried another approach and not sure if it will fly or not. Lending and then [Indiscernible] what objective for interoperability in exchange which could bring in what currently one and four. So standards where profit but also some of the other technical capabilities and infrastructure for change to occur. Two and three product capability and certification, market confidence , and not wordsmithing but try to lump these. And it seems to me that I've actually needs to be broken out based on paddies, and about something I see that's missing. This is talking about policies related to information exchange but we are missing other types of policies by the liability, like product safety and some of the of the things that our policy focused but seem to be not captured here. Just throwing that out.

Just a time check I think we have about five minutes left.

This is as it did come I'm in agreement with Patty. Some of those issues HHS has some ability to influence and others are a little tricky. Like the liability issue is largely a state law issue, not that we couldn't resolve a federal it. But we've been stymied by trying to tackle that one before. But it's definitely among a list of issues that groups up that create obstacles in some cases.

I'm just struggling to figure out how to fit in here if we don't in fact have a way to necessary to address it.

This is that do you bring up a point that might help us address this images in my support and aid to states something like appropriate federal and state governments or appropriate federal and state policies. Because as a mention, this section is largely silent about the state level. And certainly of a technical infrastructure is hope lay with ticket [Indiscernible] around the state there's still a loss about accountability as well as did exchange. I guess this is going to go back to a desk [Indiscernible] are there places where we could easily answered federal and state and would that take care of the fact that there's a pretty broad set of policies not only those related to data exchange, but also accountability and their use and accessibility by the individual. Penalties for misuse, I think that's addressed later on.

This is David. I know we are about to run out of time on this subject and I wanted to register one an additional thought. It sounds like some of these things have to be revisited. We introduced the [Indiscernible] without really defining what that is. And it seems to me that that phrase means quite different things to different people. And in a document that's to provide a five-year vision without defining it was something so fundamental is. I think leads us to some key -- confusion.

Whether we need to define it parenthetically.

I might go for a footnote or parenthetically.

I think it did but note that definition out on the web page which is different than they prototypes. That would be the place to start.

So I don't know if NHIN is the federal Health Administration effort or if it's the protocols of their using or -- it's very confusing.

Given our of time on this one, we are not like to have this one completely locked down before tomorrow. One suggestion of approach to move forward and looking for folks and put is I think we've got some [Indiscernible] and try to bring this made available for conversation with the policy committee. We may have some interesting insights from the policy committee and when Paul and I present on this we can say this is an area there are different issues we're grappling with and we're going to do more work on. And it's not quite so. Then staff can go back and talk with the folks and tried to align this better with the IFR to go as well as try to figure out how big capture some of those policy piece. Then the last caveat is folks to have any particular suggestions that we might want to work from and just send them to staff [Indiscernible] and can use that as something we can use together at a higher level. Is that an okay way to proceed, our folks comfortable that?

That sounds good to me.

What we did then is maybe try spent time next time we made it is a group that was talking about this to focus on this emailed and more and try to flesh out a little better.

Paul, what do think about that?

I think that sounds fine.

[Indiscernible] we do have time and as Judy mentioned we will get more feedback tomorrow. And bring that into our work.

I think that a lot -- there's a lot of me here and it's not as well-defined as some of this month typically because NHIN is a little bit more open with eight NHIN workgroup talking to the stuff that as opposed to a meaningful use with is a little bit more clarity on it. And it might benefit some of your discussion and the smaller group and then the large.

Would be any benefit before tomorrow's meeting that some of us got together like nine in the morning and try to hash to some of this?

I'm not sure if we would have time to pull it together and -- for tomorrows meeting. I'm not sure we'd be able to process this enough.

That makes sense.

Okay.

Not to cut off discussion at all. It would benefit more discussion. And is looking at books in the room that have to get the materials and packages out.

Right.

And I forgot, do we have another call already scheduled for this group? Or do we still have to do that?

February 9, same time, nine to noon Eastern.

Will try to pull together some of the smaller groups before that meeting.

We will go from but this simple topic to one that's even simpler which is thing three privacy and security. The advantage of this though is after we get to this conversation we do have a separate work group on privacy and security led by Devon and Rachel. So we will have the benefit of folks focusing in on this. That's one of our routes. Judy, White and a ticket from here.

Thank you, Paul. The cult here is built public trust [Indiscernible] and corporate and private interests solutions in every phase of its dormant adoption and use. And then some of the principles that were identified here where that this solution should both enhance Private insecurity of facilitating the ProTracts of information exchange to bring outcomes so there's that balance . [Indiscernible] should build trust among all the dispense and health information exchange. To take into account where the debtor is sites. The security has to include the data integrity. This a long conversation about that. The privacy interests and wishes to be flexible to let the actual involved [Indiscernible] overtime goal and that's privacy and sky solutions to be consistent with a is a high prices and secure a fair market for electronic exchange of individual [Indiscernible] information that ONC put out in December of 2008. And over again on some more detail and those are listed here. And thoughts, comments, and put on the goals and principles?

This is Paul. Security of health information includes data integrity. Is that the wording issue? Data integrity.

That's a question for the jury because I didn't write that.

I would wonder if someone could explain that then?

This is David. I'm have been the one who brought that point up. It has to do the tamperproof of the data as it leaves the hand of the crater and bounces around a perverse players. Have you know that the data has not been spooked or modified and some might. That point was missing and I think that was a trust issue that I suggested or someone suggested that the rolled up into the total concept of secured so it could be brought out as a separate point. It doesn't really matter to me.

Okay. That's helpful. It's just somehow the phrase this security of health information includes data integrity. I thought that meant something very different than what you just said.

[Overlapping speakers]

You want to ensure the security of the strike the integrity of data as is exchanged for as it stands.

I think it's brought out into a separate point about the trust in the data, data integrity is an essential to enabling trust. That's fine with me because I'm not arguing for the language as much that the notion of integrity of the did it not be lost.

This is a death. I don't disagree with that. It seems like it's a send it to a principle about solutions ought to build trust and we ought to make sure that objectives -- it seems where to put that in and an overarching principle level. To me it made a lot more and objectives. I did the addition not lost in the conversation.

The reason to elevated in my opinion is simply that if you have discussions with providers about health information exchange, it is the number one subject that comes up. How do I trust that they did that it's accurate, that it's not been tampered with. I don't have a civil conversation with that isn't the first issue that comes up.

From my standpoint, that explanation is fine. It's just an issue of word smith ago that's not what I understood when I read this.

Maybe it goes into some sort of sub bullet to the building trust principal.

Or could stay here, if it supported a little different.

The bill we can change to privacy and security solution [Indiscernible] and health information exchange including focusing on confidentiality and integrity or something like that. To make sure that it's part of what we need.

That would be nice. It's good long been.

I like that.

I like that also.

Here's another suggestion. That is the principles of the free-market are listed just by their titles. So I think it goes really empty, it doesn't really say very much. And the first sentence in that remark that goes with each of the principles is much more witnessed the conversation. Essentially an articulation of fair information practices that is covered every effort we've ever engaged in it as a nation with respect to data. Not days per se, but they are based on fair information practices. But I'd like to articulate them and more than just listing them by their title.

It wouldn't take that long to just grab the italicized sentences of each piece of the framework.

That's easy enough to do.

This is Carol. Just for what it's worth, if you have data quality integrity and the principles, and not sure why it needs to be restated.

This is Patty. What I don't see in the principles is a specific statement about integrity. And so did a quality could be assumed that the quality as they did it is acquired far as clinical some evidence or patient--

Is as it did a quality and integrity though.

I'm sorry that. What page are you on?

On the latest draft with the principles are listed.

The guiding principles?

Thing three, privacy and security, number six.

Can somebody Shamir where authentication is in there?

-- can somebody show me where authentication is now?

Rick is data quality?

I'm looking at seventh, [Indiscernible]

Doesn't have a set of bullets after that?

Page eight.

So it's embedded in that framework. And doesn't need to be pulled out a separate.

And that's if you actually have more of the sentences again, a lot of the points that we are raising our actually covered.

I think if you have one sentence explanation of them, that would be great.

So what if we add the one sentence explanation of those and drop the data integrity because it will be covered here and [Indiscernible] listed.

I think will want to see from Alex Bartlett COAT for those who aren't familiar with the former as some of us are. Nevertheless, I think people there's a log in there.

You are suggesting substituting the sentences for these six principles?

Yes.

I'm fine with that. I just wanted to understand your suggestion.

Except for number one because I'm not sure the notion that the privacy and security is an NA biller and should be viewed as an enablers today active use discloser an extensive data to improve health. May not necessarily be that articulated at quite a succinctly in the principles. But we could take a look at them and say and once the free-market those principles and the nationwide for Mark are fllushed out a bit more, could be that they exist on their own without anything else.

Maybe that should be moved up to point number one and a subsequent changes with respect to that from Mark.

Right. That's right.

I'm not sure I and the status that was mature and since we're talking about moving six of 21 [Indiscernible] and the Bullets with action have the principal list the one sentence punchball that goes with each one. And then I would say for is redundant, are others redundant?

Maybe to is redundant.

At almost think it could be a substitution.

This is Pat it. I would like to see one of the principles of expanded to have the issues of trust security integrity attached to the data and not just where the data resides. A data element been exported from any hospital to a Google health should have the protection that had at origination and not simply what the Google health was able to provide.

I don't agree with that saying that the trust has to be attached to the data. We could have a long debate about that. I don't know that I would stated that would go I think the objective is good, but saying that it's tied to the data is a difference did in.

I appreciate that. And the way I think of it in the concept of Providence. And that the data element should know something about it security status and its permission for use data. And that the road I'd be concerned about a couple of things becoming more restrictive with state it simply because it's moved to a more restrictive environment. Were actually limiting access and use today because of the Data holder, not the data owner has put some constraint on an.

Again, I think in theory that has [Indiscernible] it's difficult to impossible.

I'm curious about authentication, can anybody see that in there?

It's in the safeguards under the principle.

Yes.

You won't see on the document in front of you, Don. It's reflected in a framework which is why I was urging Margaret be in there.

The other thing, I apologize apparent I was put in the audience for about three-quarters to go on improving outcomes, I guess we could reference back up earlier, but one sense of improving and outcomes is also legitimate resurgence of four. I guess the question as is that likely to be read?

You are talking about principle one?

Yes.

Thank you.

Don, I think what we are trying to do here because I may have encouraged this articulation. This is Devon. Was to put into -- Biernath ever talking about extensive information for any old purpose whatsoever. That this entire document is talking about how we're building the tools are for improving health care and conditioning Health IT as one of those critical tools and the privacy interest provision should be facilitating the access use and disclosure of information off for that purpose . Tying it to the other piece is [Indiscernible], it could be -- I think the wording could be improved, but that was the intent.

Okay.

Let me suggest -- number six moved up to the top. Wiki Q1 but maybe need some wording change. -- we keep one but may need someone in change. And number three, I heard the debate between Patty and Carol about ticket to account [Indiscernible] attesting to the data and are we comfortable with the language as a read before or should we just dropped out one entirely?

My own sense is we should put in those of free-market principles and the SS whether there needs to be some statement about protection maybe being contextual or whenever we think we need to say in addition to that. It's very hard to wordsmith those in the absence of having that language in front of you.

This is David. I agree. It's hard to know what that means taking a to a town where the data resides, of course is it. What should it account for?

We need more context.

I think it's going to be hard to do this on the phone, I would agree. This is Patty. I do think that this is an important element to retain because a copy of the data residing in one place is different than the originating point of the data. There are certainly debates about whether the originating point should Trump every other side where the data appears and other voices addressed differently. I would say, a hit to lead a principle as it depends. Somehow we need to say something to the fact that privacy and security protections are informed by a number of aspects including with a data originated and where copies of they did it or original data are stored. And I don't know how to make that small.

This is David. I think the principle there is it should be if the goal is to manage the privacy even in the copies, then we should raise that as the issue rather than simply say the account for it.

The concern I have is the privacy blanket sometimes affairs with really good informative data integration. Either putting the patient need other a clinical setting and also sometimes it gets extended today that that are not originating in a clinical facility. But still have value to the individual. So to me, this has issues related [Coughing] when I think is fairly [Indiscernible] example the blood pressure discussion are. If you have an automatic [Indiscernible] at home and have a blood pressure checked at the clinic, can it be integrated and if they are, what level of protection that has to go on the minute you are trying to calibrate your effectiveness of your weight training program based on looking at your blood pressure. There would be reason to pull up both of them. I think we have a situation with data elements, the intended use sources should not be always driven by the least restrictive -- most restrictive privacy standard but need to have a balance between privacy and data sharing ago.

This is Judith. Can I suggest that the like we're getting in the weeds on this number three. Is taking a stand rabbit hole. It seems to me that one, it's time editor have leveled at the principle of all capture that balance the dissolution said and has perhaps Institute of facilitating [Indiscernible] information to improve outcome. Has talked about that sort of capturing the necessary the Muslims to the president's credit policies are the right one. Because there is the need for access. I still like--

I get that Jodie, I agree with you.

Interest of time, and because people don't have the actual language of the privacy and security principles and that framework laid out that we will articulate that in more detail and keep the others waved [Indiscernible] and move to the objectives so we can get the discussion on those before we run out of time.

Five minute warning.

Queue critical objectives, we only have three years ago identify and prioritize and abroad since been is for all stakeholders. Developer Mel and for his province for the laws and Kirby policies for all aspects of health IT Intel the permission exchange and trade, increase providers and individuals understanding of policies and practices to which representatives of the information.

I don't necessarily quibble with the overarching ones. I have lots of issues with a little bullets. We've got time to work with those.

With respect to number three, I think we have to be mindful of what might be a pair vaporous players that there should be in here, for example, school health. Sometimes the privacy issues are related to school and used level issues rather than clinical care per se. There issues related to reselling of anonymize did it, there's issues of data at matchups and such. I think for number three the fact that it's all a restricted to providers and individuals and not to researchers, not to pharmaceuticals, not to schools, public health, suggestion made that we need to expand this.

Good point.

We can broaden that. BID idea.

I don't think it's necessarily need to change when it to because I think one and Two are broad enough. But three did not include that.

When and to seem to have a greater givers of stakeholders. And that one was more specific.

SharePoint.

-- fair point.

You have thoughts to the work on this thing can or should relate to the privacy and security work group output?

I'm thinking. [Laughter]. I'm also curious about that because we are just beginning. This is Devon. To flesh out an agenda for topics that will take on and some sort of sense of priority order and that of course one could argue that we're attempting to formulate our own objectives. And strategic plan. Which a broader set and result providing feedback on that is always welcome. But I sort of want to understand how to make sure that we are not stepping on each other in that regard.

It may be that some of the priority areas that the workgroup is looking at may come under some strategies for dealing with this because these objectives are fairly high level. One is focusing on identifying the privacy and security and the second is the policies and the second is basically compliance of the policies, developing, providing an enforceable policies and there is educating on us. They are fairly broad. I think the workgroup is going to date in a much more detailed novel. And think through what some of those policies should be probably under one and two. So I don't think that we're going to have a consistency problem practically because the objectives as articulated are fairly broad. What we may give out and we may want to have a brainstorming session on this is think about making sure we have strategies that line with some of the priorities that work group is thinking about and that we have talked about based on what our required, what the things rhythm of doing is HHS in some of the priorities that you all have identified in the workgroup.

This is Devon. I think that makes sense. I had a lot of questions about this little bullets and their exactly and that sort of a bucket of where are the priorities with respect to specific things that need to be addressed.

So if we are just articulating this tomorrow at the level objectives, I think your right that it's completely consistent with where we've gone so far.

Okay. It sounds like--

Go ahead.

It sounds like there's a fairly good agreement on this high level enumerated objectives. And that you and say they were together again at how to harmonize the strategies.

That sounds good.

Is that there?

Great.

But, perfect timing. We will move onto theme for. This is a game where we are creating a much more of future vision of warning health system to the effectiveness of HIT. The goal of which is to transform what we have currently as a health care delivery system into a high-performance learning health system. Leveraging information and the technology. The principals are that we improve the integration between PHRs and HIT so they deliver the valued that's appreciated by the consumers and the patience. That the trans form health system is one that involves both health and health care. That HIT Foster, should empower individuals and foster environment of increased responsibility. And that there synergy amongst the HIT infrastructure and applications to create a better whole system. Maybe I should stop there and we can work on the principles first.

It's Christine, if nobody is like to jump in first I will. I have to sit at struggled with this area because I felt like a lot of them were almost more of rights and principles but not particularly specific to a learning health care system. So I made some additions and changes. I again and took out the behavior change stuff around consumers. But I thought that this should -- I didn't understand how the first and third principles of really related to a learning health care system. So I added some things like Health IT and secure information exchange should facilitate rapid learning and innovation about what works best in treatment, decision making in health outcome improvements. And then I added a second one that said Health IT and help engage patients and providers to take active roles in development and dissemination of evidence about what works best. And that I got from the idle and report on the learning health care system. I felt like it would be good to step back and really tries to refocus this area.

This is Carol. I agree with that and I like what you said Christine to go I struggled with this as of. I think the principles are to focus on integration and not enough on things like [Indiscernible] that there is knowledge improve decision making of all the participants.

This is Paul. I agree with what Christine said. I like the use of the word evidence because it seems to be a learning system . Health IT lines system seems to use the data as evidence to other decisions and continues on some sort of interest SiteScope COAT I like what Christine said.

I thought it was really well worded as well. I'd almost like to include those two that Christine mentioned and then I'm not sure I got the exact wording for Carolco [Indiscernible] and not sure any of these existing for either add or do any better than what Christine mentioned.

I sent the televisions [Indiscernible] detail revisions [Indiscernible]

If there in the spirit of what has been said by Kristin, I'm comfortable with that.

They are.

Then I had a change to the one that says, it's Kristen again, [Indiscernible] architecture should be established and I'm not sure I understand that. I will set that up front and the candid, but the piece that I added was merely a question which is whether it should stay that the infrastructure architecture should be established to sanitized awning and innovation efforts. I just wasn't understanding how that common architecture is supposed to be specific to a learning health care system. I think it comes out our debts clarify.

I had the same approach. NHIN were passed and that to some the goods that they would be helpful here. Which is methodology, policies and standards that will enable rapid and efficient creation of knowledge to improve health or to create evidence or whatever word you want to use. But it's not really, the word infrastructure is completely loaded here and it's not really clear. A methodology, policies and standards at least in the way we are thinking about NHIN, standards policies and services, if you will, is I think a better articulation.

This is pop go I. But that was written there. And part of my reaction is maybe that's a missing link for our discussion about principle No. 2 wrestling with a lot of issues. That's a good principle but it belongs more on exchange and data infrastructure. [Participant's audio is faint/unclear] MITSI was reported there semester to fall into place better.

A little bit to recount what we said last time, I think this is not well worded. But the basis of it was our discussion that to learn we need to be able to make this back to the secondary is. Its public health, clinical research, mining data for creation of a knowledge, that's I think what we meant and didn't capture well

To refresh your memory.

That's helpful. With that explanation than it does make sense to put that in there.

There really is necessary to be here.

Can you say that again?

I'm sorry for the word infrastructure, but may need some comment architecture that allows us to not only to get information to where it needs to go make individual decisions, but to support all the so-called secondary uses like public health population management, clinical research, and data mining for creation of new knowledge.

What you mean by architectural? Like we need a network or agreements about services?

As Paul said, it's a spirited to thing to. We need everything in a theme to and we struggle with how to word that and have the same struggle, but in this piece of maybe it's part of the principle, we need to leverage that common way of -- it is an infrastructure to be able to access and make use of that data. In ways that advance warning for the health system.

-- advance learning for the health system. If we can do a better job of articulating that principle that the locks and perhaps indefinitely draws on what comes out of a theme to.

I don't know how you do that, Paul. [Laughter].

[Indiscernible] is for -- infrastructure and architecture, I might suggest a [Indiscernible] definition. That's part of what you need to help drive this.

This is Jim. We might use what we hadn't into something like policy and technical specifications.

That's what I was saying before instead of architecture. I will read you the two of them together, the two bullets together and see if this works. Something like the approach should have for population health line across a large to work of this divided data sources of protecting privacy and private [Indiscernible], that's one. The second is establish the methodology, policies and standards that will enable the rapid inefficient creation of knowledge to improve health and health care.

If that can be in danger, is there a word or two words that can just grab that which is what infrastructure was supposed to be. And put and make use of that for creating the eLearning Health System?

I'm sure that's possible.

When you fix them to then we will just use that and the way would like to leverage that is to create -- we like to leverage that to create the learning health system.

So we will work on that but I think we will replace the other three with what Christine mentioned.

Maybe we should move on to objective.

This is Dave. There's one other principal that I would suggest that the concept come I've been trying to words but prodigious is to improve the public policy process to a data supported understanding of both the synergies and conflicts between individual and population health. That's clumsy, but the key is this. Will if we cannot continue to promise every individual to have everything you want whenever you want it, like you want it, and be able to afford to pay for that. And we have not [Indiscernible] average of informing individuals the cost of the system we have compared to the cost of a more communal approach of things. Does that make sense? Everyone says if you don't give me my preventative health service, then you have [Indiscernible] this service they don't realize all the of the things they've been deprived and access to because there's not enough money to pay for other things that would be Another vital and of -- benefit [Indiscernible] Bethesda integration here into public health overall level.

I understand the balance you are referring to come I'm not sure where to put it. I'm not sure it belongs in this particular theme. Perhaps there's a more overarching.

It could be, one are talking about a health care system to the effective use of HIT which is the Title IV this, I guess part of the house to do with the population health as opposed to the system itself, learning how to better manage an individual patient with cardiovascular disease. As on its summer and this, I guess. I think it could take care, but it may not.

I think population health is definitely in here. It sounds like you are bringing in the cost trade off. Which is important. [Indiscernible]

I got to find a place for that concept. And perhaps a way up in the preamble.


This is Jim. I suggest the feedback of cost is one of the things that's important. [Participant's audio is faint/unclear]

I cannot disagree with that is typical I wonder if there's a place for it and one of these objectives.

I get back to the previous discussion we had on before which is the concept of value which maybe just is not well represented here [Indiscernible]

That's a very good point. I think [Indiscernible] [Overlapping speakers]

It's not just then medical learning or -- is the whole value.

I like that as well.

Okay. Looking at the objectives, what is creation of the knowledge and tools. So people can improve their health and health behaviors. Maybe Christine can come in without and again. Another was to create the community knowledge from the providers. As a way to constantly improve. The third is, that's right this is where we have individuals, providers and communities. So there was create the community systems that of the partnerships and learning to drive there from. And here's where we started explain ourselves about number four. About this, architecture that allows this information and knowledge to be mapped. And five we threw in and added to it the public health and population health. As a way -- wanted to improved population and public health through this same base. And then I guess six was our innovations.

I will jump in on one. I would just say that what I'm going to suggest is a slide modification to what I submitted having the benefit of some sleep. That is I would say and number one, create knowledge and tools for health care professionals and for patients that promote high-quality decision making. And then I have a sub underneath it that says foster the use of and continually integrates evolving evidence into clinical decision support tools for both providers and patients. There probably tons of strategies there, but I was trying to think about things like decision support for our patients and providers, etc.

This is Carol. I have a suggestion to number two. Not necessarily to the beginning of that sentence but to add something at the and that says we talk about enhanced lifelong learning and its application to the care of individual patient. And I had something that added the concept that we want to encourage systems that can rapidly share knowledge and allow providers to work together to innovate care delivery. In other words, it's not just the creation of knowledge, but it is the collaboration and creating that knowledge.

I think that was the concept that was in the leverage but I think you said it better.

Anyway, I submitted this as part of it.

Good.

Of the architecture one, I said something like invest in technology, policies and initiatives that increase the use of improved techniques for this debited analysis -- distributed analysis and protocols or something along those lines. I cannot remember exactly what I said. I think we should get away from the idea that there's an architecture. People tend to be that as [Indiscernible] I don't think we want to [Indiscernible].

If I can say this back to Carol. Your are doing to revised that to be more functional? In its statement rather than explicitly saying something like architecture speak more to what the architecture enables?

Yes. I made a similar point in the principal section which is I think what we mean here come back protocols and methodologies and for how information is shared and used and [Indiscernible] integrated. Not necessarily building some big architecture.

This is Paul. What you said make sense to me as well because I was thinking about [Indiscernible] to do what Paul said and one of the components is data definitions become the the want to call out the definitions, it's better to say they are going to develop policies. And.

And standards and methodology. This all has to go hand in hand.

That's right. There's a number of things involved. Putting it at that high of a level make sense to me.

At the risk of, can we spend 60 seconds on try to come up with this handle. We just keep talking about it. The thing we use it for structured for, can somebody think of a better handle [Indiscernible] policy, technical standard, etc.?

What's a handle for that?

This is Jim. It really might be worth just defining infrastructure at the beginning of this and.

Use the word, but define it?

Right.

[Overlapping speakers]

There's another overused was word which is framework.

[Overlapping speakers]

I like framework.

All right, we did it. And still 15 seconds to spare. [Laughter].

Great. So a common framework that allows us to do those things. Okay.

Just so we record, I think framework is way less useful than infrastructure. I would be happy to predict in three years no one will know what we meant by its in 2010.

I appreciate that. And I think you are right, but the audience We are writing for, I think infrastructure sounds like a [Indiscernible].

Yes.

Bridges, wires, plumbing, yes.

I did it's pretty widely in common use doubt as the steps in a to make everything else work.

If we were to attach an adjective to it, I do want to get into this wordsmithing. I appreciate the point is well taken because I think are right that framework is fuzzy, infrastructure is a bit clearer to us and the fault.

[Indiscernible] I have a statement [Indiscernible] to invest in technology, policies and initiatives that increase use and improve technology -- sorry, techniques for distributed analysis unless computing, report for costs submitted, is that at a level that people are comfortable with? We can work and maybe a summary of words that and Capulets all of those things?

I think is still a little bit long and Germany.

You get and the oddest of Richard and improved techniques for distributed analysis. You did and it there. You don't need examples. I was more explaining it for you.

Invest in the technology, policies and initiatives that increased use of and approved it makes for Mr. The analysis is what I have.

It might be a good way to go right now since we don't have a term and it captures what we are all saying.

Can you come up with something else beside distributed analysis?

Yes. Great knowledge, may be?

Reading knowledge across the submitted [Audio cutting out].


That seems closed.

What was that?

Creating knowledge across [Indiscernible] data sources.

How would the other two, five and six? They feel like they are just add ons. It would nice to be have something a little bit more compelling, I guess.

46 anyway, I thought that a would be improved by saying improve population health by making information available through allied federal efforts to support achieving meaningful use and objectives such as comparative effectiveness, research and Drug said it. This is the point I've been trying to make that if the health objectives are clear that it can really prioritize and align some of these efforts.

So do we want to limit ourselves to population health? So maybe and it seems like a six we want to make sure that HIT innovations continue to create values for all dash but I'm sorry but the word stakeholders, all the people participating in care of individuals in the health of individual and population. Is that broader? The emphasis on making sure that nothing we do and did this whole winning health system impede innovation that makes more and more value for all the stakeholders.

Paul, I'm understanding what you are saying but I don't know if other people dash but I think it's a really important point to retain. So that -- I don't think they are bad as they are right now. We might revisit them again after we get feedback on them but I think five and six are pretty important to retain.

Okay.

This is Pat.

So in five then three want to only improve population health?

By making information available, etc.?

You could take that down the road of individual and population if that makes it better or upstart St. [Indiscernible] effort but the we have to start [Indiscernible] all the talk about aligning ONC with the federal initiative and not still level smoking cessation or stuff like that.

How about improve health outcomes by making it?

I could live without one. Although I'm sure that whoever raised the question earlier about the bigness, I think it can be looked on as it but I think it's comprehensive and that's [Indiscernible].


Does that work for others?

This is Jim. In a way almost what December 24 to population health.

Why do one through four don't automatically involve population health?

There would be the of the wait.

[Overlapping speakers]

Pardon?

The term provider, the words at least in two and maybe a little bit in one tend to be more targeted to the individual and not population.

Maybe it's even at the level of the gold when then.

That's interesting.

The point is everything we said in 134 much of what we said applies to population health and part of the problem is when you call it out as No. 5, I think that's part of what Poles is responding to. Kind of wobbly because you cannot be state of that. But then if you don't, what are you doing exactly? I think it would make sense to say [Indiscernible].

This is Jodie. I'm giving you your one-minute warning.

Okay.

I except that one.

This is Art. I have included at the end of that comparative effectiveness research drug safety monitoring and public health surveillance and that somehow got dropped. That's the way that Sharp was talking about dealing with many of the items of interest and that initiative to go I just wondered why that got lost?

What got lost?

The last word of public health surveillance.

I see.

I would agree that should be added.

We are talking about population health because that's about the providers of that will come from people who do that type of comparative research, the monitoring and surveillance activities.

I want to be respectful of the timekeeper, what I heard from Jim is to elevate population to the goal so we can find a way to work it into the bowl. Then maybe instead of five looking like it only does the population health to talk about how we're going to use this warning system to apply the creation of new knowledge and that includes the [Indiscernible] drug money tree and public health surveillance.

Does that help capture it, Art?

Yes. Right. And other thought lost in this translation and our discussion last week, we had the concept of social determinant of Health and we seemed to have lost that again.

It's up there in three.

Okay.

I guess I'm looking at the wrong--

There are two versions. What is edited.

Okay.

Surpassed the one minute mark in that think it's pretty good. I think we have enough to start the discussion at the meeting tomorrow. Will get additional input from the committee members and turnaround a draft that incorporates both the comments we have today. Hopefully some of this will get into what we present tomorrow and the feedback we get from committee and that will be the basis for us to have our next call. We are still going to try to hammer out some of the stuff in parallel. I think that's been useful. That helps us be more productive with a time that we spend together like this call. At this point, I'd like to -- any final comments from the worker members before we open it up to the public?

While people are thinking, other any public comments indicated?

I don't ask the operator is anybody on the line to comment and then you can continue.

I want to take a minute to thank you for your leadership go you are incredible. This is a very effectively run meeting. And Jody, the Santee. You prepared this well.

Thank you, head. We appreciate the folks spending time on this and such productive comments.

This is Deb, I am appreciative of the drafters to put the words out there for us to pick up part. It's not always easy but it's a necessary function to be able to allow us to move forward. Much appreciated.

Absolutely.

This is Allison to go just wanted to remind everyone how to make a public comment. If you dial 877705 to 976 if you press *1, you will be placed into a queue to make a public comment.

We do not have any public comments thus far.

Okay.

So for the worker members will be back in touch with you about follow up calls. We have one in February and schedule some additional ones to start work on these parallel things. What's been, thank you so much for taking the time the matter what time zone you are in. To participate with this and create and continue to improve this document which I think is coming along nicely.